Deficiencies in Resident Dignity and Care
Penalty
Summary
The facility failed to ensure residents were treated with dignity during activities of daily living (ADLs) care and failed to provide care upon request for several residents. Resident #254 reported feeling uncomfortable when staff spoke in foreign languages during care, which she could not understand. Resident #251 described the staff as rough, pushy, and disrespectful, noting that they did not greet him or work well together. Resident #256's wife expressed concerns about the refusal of aides to shave him, despite her providing a razor, and noted that the aide did not perform the task well. Resident #55 found it rude when staff did not speak English while providing care, and Resident #83 reported that staff had a nasty attitude and argued while caring for her. Resident #250 experienced delays in receiving assistance for a "diaper" change, with aides showing an attitude and not responding promptly to her requests. She also mentioned filing a complaint without receiving feedback on the resolution. Resident #23 highlighted issues with the lack of hot water in her bathroom and recounted an incident where a CNA poured cold water on her, causing her to stop breathing momentarily. The Director of Nursing was informed of these concerns, and Staff E, a nurse, expressed discomfort with staff communicating in a foreign language in front of residents. These incidents reflect a pattern of inadequate care and communication, leading to residents feeling disrespected and neglected in their care needs.
Plan Of Correction
Preparation and/or execution of this plan does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusions set forth on the statement of deficiencies. This plan of correction is prepared and/or executed solely because it is required. (1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 4.4.25 residents #254, 251, 256, 55, 83, and 23 were assessed by licensed nurse, no concerns identified related to alleged deficient practice. Resident #251 discharged on 4.9.25 and is no longer residing in the facility. Resident #256 discharged on 4.8.25 and is no longer residing in the facility. Resident #250 discharged on 4.2.25 and is no longer residing in the facility. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On 4.11.25 the Director of Social Services completed a quality review of current residents to ensure that residents rights are honored with emphasis treating residents with dignity and respect, communicating in a language that residents can understand, providing shaving assistance to dependent residents, providing water temperatures for bathing/hygiene at preferred temperatures, and timely response to call lights. Any concerns identified were corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: On 4.17.25 Ad Hoc Resident council meeting held to review survey results and plans being implemented for correction of alleged deficient deficiencies. On 4.22.25 the Director of Nursing completed education with current staff on the components of F550 Resident Rights with an emphasis on treating residents with dignity and respect, communicating in a language that residents can understand, providing shaving assistance to dependent residents, providing water temperatures for bathing/hygiene at preferred temperatures, and timely response to call lights by the Assistant Director of Nursing/designee. Newly hired staff will be educated on the components of F550 Resident Rights with an emphasis on treating residents with dignity and respect, communicating in a language that residents can understand, providing shaving assistance to dependent residents, providing water temperatures for bathing/hygiene at preferred temperatures, and timely response to call lights by the Assistant Director of Nursing/designee at orientation as a part of the systematic changes. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Director of Nursing/Designee to conduct random audits of 5 residents 2 times a week for 4 weeks, then once a week for 4 weeks and then monthly for 1 month to ensure compliance with F550 residents' rights are honored with emphasis on treating residents with dignity and respect, communicating in a language that residents can understand, providing shaving assistance to dependent residents, providing water temperatures for bathing/hygiene at preferred temperatures, and timely response to call lights. The findings of these quality monitoring to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.