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F0550
D

Failure to Ensure Resident Dignity and Access to Appropriate Clothing

Saint Paul, Minnesota Survey Completed on 04-24-2025

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 provide a dignified experience for two residents by not ensuring they had appropriate clothing and by allowing staff to speak to a resident in an undignified manner. One resident, with diagnoses including weakness, morbid obesity, and bipolar disorder, required assistance with dressing and reported being scolded by a nursing assistant after accidentally soiling her shirt. The resident stated she felt she was treated like a child and had reported the incident to a nurse, who was supposed to notify the assistant director of nursing (ADON). However, the ADON did not recall receiving the grievance form and had not followed up on the report until the resident brought it up again. Another resident, with chronic medical conditions and moderately impaired cognition, was observed without clothing except for a robe and slippers. The resident stated she had no other clothing at the facility, as her belongings remained at her previous group home and the facility no longer provided gowns. Staff interviews confirmed the resident's lack of clothing and indicated that attempts to retrieve her belongings had been unsuccessful. The social services staff and ADON acknowledged the dignity concern of the resident not having appropriate clothing for an extended period. Facility policy requires residents to be treated with dignity and respect, including being encouraged to dress in their preferred clothing and being spoken to respectfully at all times. Despite this, the facility did not ensure that the residents had access to appropriate clothing or that staff consistently interacted with residents in a dignified manner, resulting in a failure to honor the residents' rights to dignity and self-determination.

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