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F0550
D

Failure to Ensure Resident Dignity and Protection from Retaliation by LPN

Folkston, Georgia Survey Completed on 05-07-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect and maintain the rights and dignity of three residents by not ensuring that a staff nurse, an LPN, treated them with dignity and respect in a manner that promoted or enhanced their quality of life. Multiple residents reported that the LPN displayed a consistently negative attitude, did not communicate during care, and failed to ask about their well-being or needs. Residents described instances where the LPN withheld or delayed medications, did not respond to call lights, and ignored requests for assistance, often telling residents to ask a CNA instead. There were also reports that the LPN spoke negatively about residents to others and made disparaging remarks, particularly targeting smokers and certain groups, and used strong sprays in residents' rooms after making negative comments about the smell of smoke. Residents expressed a pervasive fear of retaliation if they reported the LPN's behavior, stating that the LPN would ignore them, withhold care or medications, and generally make their lives more difficult if she discovered they had complained. This fear led to underreporting of grievances and complaints, despite residents being aware of the grievance process. The issue was corroborated by interviews, resident council minutes, and a Long Term Care Ombudsman report, all of which documented ongoing concerns about disrespectful treatment, delayed care, and a hostile environment created by the LPN, especially during night shifts. The facility also experienced high management turnover and chronic understaffing, particularly on nights and weekends, which contributed to unmet resident needs and further reluctance to report issues. The affected residents had significant medical and functional needs, including conditions such as diabetes, multiple sclerosis, amputations, depression, anxiety, and chronic pain, requiring regular assistance with activities of daily living and timely administration of medications. Despite these needs, the LPN's conduct resulted in residents feeling anxious, neglected, and apprehensive about seeking help. The lack of visible signage for reporting abuse or complaints further hindered residents' ability to seek recourse, as confirmed during a facility walkthrough where required posters were found missing.

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