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F0600
D

Failure to Prevent Verbal Abuse of Cognitively Impaired Residents

West Burlington, Iowa Survey Completed on 05-01-2025

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

Staff at the facility failed to protect residents from verbal abuse, as evidenced by multiple incidents involving three residents with severe cognitive impairments and behavioral symptoms. Staff F was reported to have used vulgar and derogatory language towards residents, including telling one resident to 'sit your f**** a*** down,' calling another a 'b****,' and instructing a resident to 'shut the f*** up and sit down.' These actions were witnessed and documented by other staff members, including a CNA and a housekeeper, who reported that Staff F frequently used a 'filthy mouth' and was very vulgar to residents. The incidents were not reported immediately by all staff, with one CNA stating she delayed reporting due to having to work regularly with Staff F. The residents involved had significant cognitive and behavioral challenges, including diagnoses such as non-Alzheimer's dementia, anxiety disorder, chronic kidney disease, non-traumatic brain dysfunction, irritability, anger, and hypertension. Their care plans specifically directed staff to use gentle communication, reassurance, and emotional support. Despite these directives and facility policy prohibiting verbal abuse, staff failed to adhere to appropriate standards of conduct, resulting in residents being subjected to disparaging and derogatory language.

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