Dignity in Dining Experience Not Maintained
Summary
The facility failed to ensure a dignified dining experience for two residents during the recertification survey. Resident #2, who was admitted with severe cognitive impairment and required extensive assistance for eating, was observed being fed by a Certified Nurse Aide (CNA) who stood over the resident while assisting with their meal. The CNA acknowledged awareness of the requirement to sit at eye level with residents during feeding but chose to stand for personal comfort. Similarly, Resident #113, who also had severe cognitive decline and was totally dependent on staff for eating, was observed being fed by another CNA who stood over the resident due to the unavailability of chairs. This CNA also acknowledged the requirement to sit at eye level with residents during feeding. A Licensed Professional Nurse confirmed that CNAs should always be at eye level with residents to maintain dignity during meals.
Plan Of Correction
Plan of Correction: Approved April 23, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Corrective Actions for Residents Identified Residents #2 and #13 Resident Rights The resident has a right to a dignified existence and respect. Residents #2 and #13 suffered no ill effects related to deficient practice. Residents will be provided with dignity and respect as evidenced by staff will be seated next to residents at eye level that require assist with meals. Resident Rights Following notification of this deficiency, resident #2 was assessed on 4/1/25 and found to have no [MEDICATION NAME] ill effects related to this deficient practice. Resident #13 was assessed on 4/1/25 and found to have no [MEDICATION NAME] ill effects as a result of this deficient practice. Aide #13 and Aide #5 were re-educated on 4/1/2025 on resident’s rights and the procedure for providing feeding assistance, the need to sit beside residents while providing assistance with feeding. Resident at Risk Any resident can be affected by this deficient practice. The Director of Nursing conducted an audit to identify any other resident who was affected by this deficient practice and none was identified. The facility respectfully states that while all residents had the potential to be affected by this deficiency, no other resident was found to be affected. The Administrator/Designee has conducted an audit of chairs within the facility, available for use by staff providing feeding assistance, and found that there are sufficient numbers of available chairs. Dependent residents can be affected by this deficient practice. Systemic Changes All nursing staff (CNA’s and Nurses) will be educated by Nurse Staff Educator/ADON/Designee on procedure with assisting residents with eating during meals. Specifically, staff should be seated next to resident at eye level while assisting with meal. The Administrator has reviewed the facility’s Policy on Quality of life-Dignity, and found it to be in compliance with all state and federal regulations. Education will be provided to all Nurses and CNAs on the procedure for providing feeding assistance, specifically, staff should be seated next to the resident and at eye level while assisting with meals. Monitoring for Corrective Action The DON has created a meal time audit to monitor for staff sitting while providing feeding assistance. Meal time audits will be conducted for lunch & dinner daily x 2 weeks, then weekly x 2 weeks, then monthly x 3 months. Audits will be presented at QAPI meetings monthly by the DNS to determine continued need. Review of Nursing staff attendance and completion of education will be monitored by Nurse Staff Educator/ADON/DNS. The DNS/Designee will be responsible for completion of this plan of correction. Responsible: The DNS/Designee will be responsible for completion of this plan of correction. Completion Date: 5/31/2025
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to maintain resident dignity was identified when three residents with indwelling urinary catheters had drainage bags hanging on the bedframe without privacy covers, despite physician orders for privacy covers every shift. In addition, a resident who was ordered to be fed by staff was observed being fed by a nurse aide standing beside the bed during lunch, and the DON confirmed the dining experience was not dignified.
A resident with dementia, anxiety, and osteoarthritis was observed sitting naked on the bed in full view of the hallway while a CNA assisted with dressing. The care plan directed staff to assist with dressing, and the CNA stated the curtain had not been pulled after returning the resident from the bathroom. The ED confirmed the facility failed to maintain the resident's dignity.
Failure to provide a dignified dining experience: Four residents with significant diagnoses, including Parkinson’s disease, schizophrenia, cerebral palsy, TBI, and dysphagia, were brought to the assistive dining room for lunch but were not served their trays until more than 50 minutes after the posted mealtime. While other residents were already being assisted with eating, these residents were left watching the meal service, and the DON stated they should have been served at the same time as the others or not brought in until their trays were ready.
A facility failed to protect the dignity of two residents when an LPN administered insulin injections in the commons area in full view of surveyors, staff, and other residents. The LPN lifted each resident’s shirt, cleansed the injection site, and gave the subcutaneous insulin injection publicly rather than in a private area.
A resident with dementia, depression, and anxiety was seated in the dining room while other residents ate, but the lunch tray was not served with the group on two occasions. In a separate event, an LVN administered oral meds to another resident with intellectual disability and cerebral palsy in the dining room while wearing gloves, rather than in a private setting, which staff stated was not the facility’s practice and could be seen as disrespectful.
A resident with dementia and Alzheimer's disease had his beard completely shaved by two CNAs without his RP's consent. The RP stated the resident had worn his beard for many years and had not been seen without it, and the DON stated the RP should have been notified because the resident lacked capacity to make decisions for himself. The facility policy required staff to ask the resident or, when appropriate, the resident representative about grooming preferences upon admission.
Failure to Maintain Resident Dignity During Catheter Care and Dining
Penalty
Summary
The facility failed to maintain resident dignity by not ensuring privacy covers were applied to urinary catheter drainage bags for three residents. Resident R26, who had diagnoses of diabetes, high blood pressure, and coronary artery disease, had a physician order for catheter care to provide a privacy cover for the drainage bag every shift. During observation, the catheter drainage bag was hanging on the bedframe without a privacy cover. Resident R178, with diagnoses of diabetes, high blood pressure, and depression, also had an order for a privacy cover every shift, and the drainage bag was observed hanging on the bedframe without a privacy cover. Resident R179, diagnosed with COPD, atrial fibrillation, and heart failure, likewise had an order for a privacy cover every shift, and the drainage bag was observed hanging on the bedframe without a privacy cover. An RN confirmed that the bags should be covered and that the residents' dignity was not maintained. The facility also failed to provide a dignified dining experience for one resident who was ordered to be fed by staff. Resident R39, who had diagnoses of high blood pressure, heart failure, and diabetes, had a care plan and physician order for staff to feed all meals. During lunch observation on the 2B nursing unit, the resident was sitting upright in bed while a nurse aide stood beside the bed feeding the resident. The nurse aide stated that they should have been sitting down while feeding but did not know where the resident's chair was. The DON later confirmed that the facility failed to provide the right to a dignified dining experience for one of two lunches observed on 2B.
Failure to Maintain Resident Dignity During Dressing Assistance
Penalty
Summary
The facility failed to provide care and services to maintain a resident's dignity for one of 11 sampled residents. Resident R23 had diagnoses including dementia, anxiety, and osteoarthritis. The MDS dated [DATE] indicated the resident had mild cognitive impairment and required assistance with dressing. The care plan identified a self-care performance deficit related to dementia and directed staff to assist the resident with dressing. During observation on 8/4/2026 at 10:15 a.m., Resident R23 was sitting on the bed naked in full view of anyone walking by in the hallway while a CNA was assisting with dressing. During interview, the CNA stated that the curtain had not been pulled after bringing the resident back from the bathroom, and the Executive Director confirmed the findings and that the facility failed to provide care and services to maintain the resident's dignity.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect for 4 of 8 residents reviewed for respect and dignity. The facility’s Assistance with Meals policy stated that staff will serve resident trays and help residents who require assistance with eating, and that residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity. The facility’s Dignity policy stated that each resident shall be cared for in a manner that promotes and enhances well-being, satisfaction with life, and feelings of self-worth and self-esteem, and that residents are supported in exercising their rights during care. Resident #4 had diagnoses including Parkinson’s Disease and major depressive disorder. Resident #13 had diagnoses including schizophrenia and abnormal involuntary movement. Resident #19 had diagnoses including spastic quadriplegic cerebral palsy and anxiety disorder. Resident #44 had diagnoses including traumatic brain injury and dysphagia. During observation of the assistive dining room during the lunch meal, eight residents were present and only four were being assisted with eating after their meals had been delivered. Residents #4, #13, #19, and #44 were not served their lunch trays until after 12:10 PM, more than 50 minutes past the posted lunch mealtime, and were observed watching other residents who were already being assisted with their meals. The DON stated these residents should have been served at the same time as the other residents or not brought into the dining room until their trays were ready.
Failure to Protect Resident Dignity During Insulin Administration
Penalty
Summary
The facility failed to provide care for R4 and R1 in a manner that protected and promoted their dignity. On 08/04/2026 at 07:32 AM, observation in the commons area showed LN G pulling up R4's shirt on his left arm, cleansing the area with an alcohol wipe, and administering a subcutaneous insulin injection in his right upper arm while two surveyors, multiple facility employees, and numerous other residents could view the procedure from the four halls and dining room area. On 08/04/2026 at 07:40 AM, a similar observation in the commons area showed LN G pulling up R1's shirt on his left arm, cleansing with an alcohol wipe, and administering a subcutaneous insulin injection in his right upper arm in full view of two surveyors, multiple facility employees, and numerous other residents. On 08/05/2026 at 08:10 AM, Administrative Nurse D verified that LN G should not administer insulin injections in public areas and that residents should be taken to their rooms or a private area. The facility's Respect and Dignity; Right to Personal Property policy, dated August 2026, stated residents have the right to be treated with respect and dignity.
Late Meal Service and Public Medication Administration
Penalty
Summary
Facility staff failed to promote dignity and respect for Resident 3 when the resident’s lunch tray was not served with the other residents in the dining room on 7/30/2026 and again on 7/31/2026. Resident 3 was admitted with diagnoses including dementia, major depressive disorder, and anxiety, and the MDS indicated the resident had moderately impaired cognitive skills for daily decision making and required supervision or substantial assistance with multiple activities of daily living. During observation, Resident 3 was seated at a dining table with other residents while the other residents were eating, but Resident 3 had no lunch tray present. During the first observation, Treatment Nurse 1 verified that Resident 3 had no lunch tray and was watching the other residents eat, and stated he did not know why the tray was not included with the others. The Assistant DON later stated the resident was not served lunch on time and should have been served between 12:00 PM and 12:15 PM with the other residents in the dining room. On the second day, Resident 3 was again observed seated at the dining table at 12:15 PM with no lunch tray while other residents were eating. The DON and Dietary Supervisor stated the delay left the resident waiting while others ate, and the Dietary Supervisor stated the system for getting the dining room resident list to the kitchen staff was not working. Facility staff also failed to maintain Resident 4’s dignity during medication administration in the dining room. Resident 4 was admitted with diagnoses including mood disorder, intellectual disability, and cerebral palsy, and the MDS indicated the resident required substantial assistance with several activities of daily living. During observation, LVN 1 administered oral medication to Resident 4 in the dining room while wearing gloves. Treatment Nurse 1 stated medication should not be given in a public area and that the resident should have been assisted back to the room for private medication administration. The DON stated the resident could feel disrespected and that other residents might think the resident had an infectious disease because staff wore gloves while giving the medication.
Unauthorized Shaving of Resident's Beard
Penalty
Summary
The facility failed to ensure that two CNAs did not shave the beard of one resident without the resident's RP's consent. The resident had diagnoses including dementia and Alzheimer's disease, and his MDS indicated his cognition was moderately impaired and that he was dependent on facility staff for ADLs. The resident's RP stated that the beard was shaved without her knowledge or consent and that the resident had worn his beard for many years and she had never seen him without it. The DON stated that the RP should have been notified before the resident's beard was shaved because the resident did not have capacity to make decisions for himself. The DON also stated that CNA 1 and CNA 2 reported the resident looked unkempt and dirty on admission and that they felt he needed grooming. The facility policy on resident preferences stated staff should ask the resident and, when appropriate, the resident representative about preferences upon admission before initiation of treatment/therapy and/or during the initial IDT meeting, including preferences related to grooming.
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