Failure to Provide Timely ADL Assistance and Call Light Response, Compromising Resident Dignity
Summary
The facility failed to ensure timely assistance with activities of daily living (ADLs), specifically toileting, and did not respond promptly to call lights, compromising the dignity of several residents. One resident with severe cognitive impairment and frequent incontinence was observed repeatedly requesting help to use the bathroom over a 35-minute period, both verbally and by seeking out staff, but did not receive assistance. During this time, staff members, including CNAs and a patient aid, informed the resident that they could not help due to being occupied with feeding other residents, and the resident ultimately experienced an episode of incontinence in a public area, becoming visibly upset and distressed. Other residents also reported excessive wait times for call lights to be answered, with some stating they had to attempt self-toileting to avoid accidents, despite requiring assistance. Multiple residents described call light response times as too long, sometimes up to an hour, particularly during meal times or when staffing was reduced. Staff interviews confirmed that there were not enough CNAs on duty to meet residents' needs in a timely manner, and that they were instructed not to interrupt feeding to provide toileting assistance. Facility policies reviewed by the surveyor required prompt response to residents' requests for toileting assistance and call lights, and prohibited practices that compromise resident dignity. Despite these policies, staff actions and statements indicated that care was delayed due to staffing shortages and prioritization of other tasks, resulting in residents' needs not being met in a manner that promotes dignity and respect.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with cirrhosis, ascites, mood disorder, and alcohol-induced major neurocognitive disorder, and with moderately impaired cognition, was observed sitting on a shower chair in a gown with buttocks exposed and visible from the hallway through an open room door. A CNA left the room quickly after hearing another resident yell and forgot to close the door or pull the privacy curtain, and an RN confirmed the exposure, demonstrating a failure to maintain the resident’s dignity and privacy.
A resident with severe cognitive impairment, dementia, dysphagia, and other comorbidities required maximum assistance with eating, but a CNA failed to provide dignified feeding assistance. The CNA delivered the breakfast tray and left, then later sat at the bedside watching social media on a personal cell phone with an earbud in while nominally assisting with the meal. The CNA offered one food item but fed another, did not consistently alert the resident before offering bites, and at times held food at the resident’s mouth without explanation or was occupied cleaning and reloading the spoon while the resident waited with mouth open. Facility leadership confirmed staff should not use cell phones during resident care, and policy required a relaxing, enjoyable mealtime environment.
Surveyors found that the facility failed to maintain resident dignity by serving meals in Styrofoam containers with plastic cutlery for an extended period due to a malfunctioning dishwasher that left reusable dishes unclean. All but three NPO residents were affected, and a resident reported difficulty cutting food because the utensil would cut through the Styrofoam. Observations on multiple meal services confirmed ongoing use of disposable dishware, which conflicted with the facility’s written dignity policy requiring care that promotes quality of life, respect, and individuality.
A cognitively intact resident with significant physical impairments, including spinal muscular atrophy, hemiplegia, and type 2 DM, reported that a CNA was not treating him respectfully. Documentation and interviews showed that when the resident asked the CNA if she was ignoring him, the CNA replied that she was ignoring him. An SRI was initiated for an abuse allegation, and although abuse was not substantiated, the facility determined that the CNA had spoken to the resident in a disrespectful manner, resulting in a dignity-related deficiency affecting one resident.
A cognitively intact resident with Parkinson’s disease, muscle wasting, and muscle weakness, who required substantial assistance with dressing, was observed lying in bed with the door and curtain open, wearing only a t-shirt and incontinence brief and without any blanket or sheet available for coverage, leaving the resident exposed and uncomfortable. Staff confirmed the resident was visible from the hallway and should have been covered. The same resident’s care plan required that the call light be kept within reach, yet on multiple occasions the call light was placed near the resident’s shoulder, beyond the resident’s functional reach due to limited arm and hand mobility. Staff acknowledged they had not ensured the call light was accessible, and a family member reported repeatedly finding the call light out of reach during visits.
A resident with functional quadriplegia, dysphagia, and multiple comorbidities, who was documented as fully dependent on staff for eating, had a lunch tray placed at the bedside and left untouched for an extended period before staff came to assist. The resident reported routinely waiting several minutes to as long as half an hour while the tray sat in front of him, stating he had to sit and look at it. Surveyor observations confirmed the tray remained untouched for a prolonged time with no staff assistance, and the DON acknowledged this constituted an undignified meal experience.
Resident Left Exposed and Visible From Hallway Due to Failure to Maintain Privacy
Penalty
Summary
The facility failed to ensure resident dignity and privacy when a cognitively impaired resident was left exposed and visible from the hallway. The resident, who had diagnoses including cirrhosis with ascites, mood disorder, and alcohol-induced major neurocognitive disorder, had a BIMS score of eight, indicating moderately impaired cognition. During an observation, the resident was seen sitting on a shower chair in a gown with buttocks exposed, and this exposure was visible from the open room door in the hallway. A Certified Resident Care Associate and a Registered Nurse confirmed that the resident’s buttocks were visible from the hallway. The Certified Resident Care Associate reported that she had left the resident’s room quickly after hearing a resident in an adjacent room yell and, in her haste, forgot to close the door or pull the privacy curtain, resulting in the resident’s exposed state being visible to others. This incident involved one resident out of three reviewed for dignity, in a facility with a census of 52 residents, and was identified through record review, observation, and staff interviews.
Undignified Feeding Assistance While CNA Used Personal Cell Phone
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received feeding assistance in a dignified manner consistent with the resident’s rights and facility policy. The resident had diagnoses including Alzheimer’s disease, stroke, anorexia, dysphagia, and dementia with agitation, and a quarterly MDS showed severely impaired cognition with a need for supervision/touching assistance for eating. The care plan documented an ADL self-care performance deficit related to dementia, with interventions indicating the resident required maximum assistance and might need to be fed by staff. On the morning in question, a CNA brought the resident’s breakfast tray into the room and then left to continue passing other trays. Later that morning, the resident was observed sitting up in bed with the CNA seated next to the bed and the overbed table positioned in front of the CNA. The CNA was wearing an earbud and watching a video on her personal cell phone, which she confirmed was social media, while she was supposed to be assisting with feeding. Although the CNA asked the resident if she wanted eggs and the resident nodded and opened her mouth, the CNA instead fed the resident yogurt, which she acknowledged. During the meal, the resident’s eyes were periodically closed, and the CNA would hold a spoonful of food at the resident’s mouth without notifying her that another bite was being offered. At other times, when the resident opened her mouth in apparent anticipation of food, the CNA was occupied with cleaning and reloading the spoon without verbalizing what was occurring. The Interim DON confirmed staff should not watch their cell phones while providing resident care, and facility policy stated that mealtimes should provide a relaxing, enjoyable environment.
Failure to Maintain Dignity by Serving Meals on Disposable Dishware
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to dignity and respect by serving meals on disposable Styrofoam dishware with plastic cutlery for an extended period. Surveyors observed that the facility’s dishwasher had been malfunctioning since February, dispensing chemicals at incorrect times and leaving dishes unclean. As a result, the facility had been using disposable dishware for all meals, affecting 67 residents, while three residents who were NPO did not receive food from the kitchen. During a kitchen observation, the dishwasher was noted to be non-operational and under repair by a technician, and subsequent meal service observations showed residents receiving their meals in Styrofoam containers with plastic utensils. A resident reported dissatisfaction with the Styrofoam containers, stating that it was difficult to cut food and that attempts to do so resulted in cutting through the container itself. Multiple observations of lunch services confirmed that residents continued to be served meals in Styrofoam containers with plastic utensils. Review of the facility’s “Quality of Life – Dignity” policy, dated August 2009, indicated that each resident should be cared for in a manner that promotes and enhances quality of life, dignity, respect, and individuality, and that staff should promote, maintain, and protect resident privacy. The use of disposable dishware and cutlery during meal services was determined to be inconsistent with these dignity standards, leading to the cited deficiency under the referenced complaint number.
Failure to Ensure Respectful Communication Toward a Cognitively Intact Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff spoke to a resident in a respectful manner, thereby not honoring the resident’s right to dignity and respectful communication. The resident involved was admitted with diagnoses including spinal muscular atrophy, hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, and type 2 diabetes. A nurse progress note documented that a CNA had not treated this resident respectfully. An MDS assessment showed the resident was cognitively intact and required moderate to maximal assistance with staff for all ADLs. The resident later confirmed in an interview that he did not want this CNA to care for him anymore due to how she had treated him. The facility’s SRI documented that the resident made an allegation of abuse involving the CNA. While the facility’s investigation did not substantiate abuse, it did determine that the CNA spoke to the resident in a disrespectful manner. The DON reported that the resident had complained that when he asked the CNA if she was ignoring him, the CNA responded that she was ignoring him. The DON confirmed that the CNA admitted the resident’s account of the incident was correct. This conduct constituted a failure to ensure that staff communicated with the resident in a respectful manner, affecting one resident reviewed for dignity and respect out of a facility census of 69.
Failure to Maintain Resident Dignity and Ensure Accessible Call Light
Penalty
Summary
The deficiency involves the facility’s failure to maintain dignity, privacy, and appropriate coverage for a cognitively intact resident with Parkinson’s disease, muscle wasting, muscle weakness, and adult failure to thrive. The resident, admitted in late June 2025 and requiring substantial/maximal assistance with upper and lower body dressing, was observed lying in bed with the room door and privacy curtain open, wearing only a t-shirt and incontinence brief, and without any blanket or sheet available for covering. The resident stated he was not comfortable being uncovered and exposed and wanted to be covered. A personal care aide confirmed that the resident could be seen from the hallway, had no blanket or sheet, was only in a t-shirt and incontinence brief, and acknowledged the resident should have been covered. The facility also failed to ensure the resident’s call light was within reach, despite a care plan directive that staff ensure the call light remained accessible. On multiple observations, the resident was lying in bed with the call light placed near or over his right shoulder, which he confirmed he could not reach due to limitations in his hands and arms. One personal care aide confirmed at the time of observation that the resident could not reach the call light, and another aide admitted she had completed personal care and left the room without ensuring the call light was within reach. A physical therapist reported that, due to Parkinson’s disease, the resident’s ability to move his arms and hands varied by day but was limited on an ongoing basis. The resident’s uncle reported that on numerous occasions during visits he observed the call light was not within the resident’s reach.
Undignified Dining Experience for Dependent Resident
Penalty
Summary
A resident who was functionally quadriplegic and dependent on staff for all self-care and mobility, including eating, was not provided a dignified dining experience when staff left his lunch tray at his bedside and did not return to feed him for an extended period. The resident had diagnoses including Guillain-Barre syndrome, dysphagia, urinary retention, diabetes mellitus, hyperlipidemia, and hypertension, and his care plan and functional assessment documented that he was dependent on staff for eating. During an observation at 11:55 A.M., the resident’s lunch tray was seen untouched on his bedside table, and the resident stated that staff come to feed him only after all meal trays have been delivered, reporting that he may wait from eight to 30 minutes while the tray sits in front of him, saying, “I have to sit and look at it.” A follow-up observation at 12:10 P.M. showed the tray remained untouched and no staff had come to feed him. In an interview at 1:00 P.M., the DON confirmed that leaving the meal tray in front of a resident who could not feed himself constituted an undignified meal experience. This deficiency was cited for one resident under Complaint Number 2740077.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
