Failure to Provide Dignity and Respect to Residents
Summary
Staff failed to provide dignity and respect to two residents. For one resident with neuromuscular bladder dysfunction, depression, and nicotine dependence, a CNA made an inappropriate gesture by lifting her own breasts over her shirt in front of the resident during care. The CNA admitted to making the gesture in an attempt to be funny, but the resident did not find it humorous and reported the incident occurred about a month prior to the interview. For another resident with severe cognitive impairment, memory problems, and total dependence for activities of daily living, staff did not interact with or ask the resident before placing a clothing protector on her in the dining room. Additionally, a CNA referred to the resident as the "only true feed" in the dining room, a term acknowledged by the CNA as disrespectful. Both staff members confirmed their actions during interviews. Facility policy requires residents to be treated with respect and dignity, but these actions did not meet that standard.
Plan Of Correction
F557 The facility failed to maintain the dignity of residents; A) a STNA #206 referred to residents requiring assistance with food and fluid intake as "Feeds," B) a STNA #222 applied a clothing protector on resident #21 prior to asking permission to do so and waiting for a reply, and, as well as C) a STNA #240 made an inappropriate gesture in regard to breasts in the presence of resident #22. Step 1: The facility DON immediately... A) Educated the STNA #206 on the inappropriateness of referring to residents in terms of needs, diagnoses or other identifiable qualifiers, emphasizing the importance of using more appropriate terminology such as "residents requiring assistance with..." on 6/3/25. B) Educated STNA #222 on the need to ask and wait for reply prior to applying items such as clothing protectors to residents and if resident is unable to reply or understand on 6/3/25, IDT to discuss with resident representative and ensure stated desires are care planned. Completed on 6/27/25. C) SRI opened and investigation initiated. Completed on 6/10/25. Step 2: To identify other residents that have the potential to be affected... A) DON or designee reviewed current residents that require assistance with oral intake. B) DON or designee reviewed current non-verbal and/or cognitively impaired residents that might use clothing protectors during meals. C) Resident interviews with interview-able residents and skin sweeps on non-interview-able residents completed with no negative findings (R/T SRI). Completed on 6/27/25. Step 3: To prevent this from recurring... A) DON or designee will educate staff on the inappropriateness of referring to residents in terms of needs, diagnoses or other identifiable qualifiers, emphasizing the importance of using more appropriate terminology such as "residents requiring assistance with..." Completed on 7/11/25. B) DON or designee will educate staff on asking residents permission and waiting for a response prior to applying a clothing protector and for non-verbal residents to verify use on care profile or care plan. Completed on 7/11/25, for non-verbal and/or residents that are unable to respond the DON or designee will contact the residents' responsible party to discuss use of clothing protectors during meals and update the residents' care plans and care profile with responsible party's desires related to the use of clothing protectors. Completed 6/27/25. C) LNHA educated current staff on the Abuse, Neglect, and Misappropriation Policy and Procedure. Completed on 6/7/25. STNA #240 was educated by the facility Staffing Coordinator on 6/16/25 prior to returning to work. Step 4: To monitor and maintain ongoing compliance... A) DON or designee will audit 5 staff members per week x4 weeks then monthly x2 months for appropriate responses. B) DON or designee will review new admissions for ability to determine desire for clothing protector use and if non-verbal or cognitively impaired will discuss with responsible party then update care plan and profile as indicated in addition to auditing 3 non-verbal/cognitively impaired residents weekly x4 weeks then monthly x2 months for clothing protector use in relationship to care planned desires. C) DON or designee will interview 3 residents per week x4 weeks then monthly x2 months to ensure appropriate staff behavior while providing care or in resident areas. Audits will begin 7/14/25. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations. F565 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 07/30/25 as the facility's allegation of compliance date. The facility failed to ensure that resident concerns were addressed in a timely manner or resolved affecting resident #24, #35, and #29. Step 1: Concerns that were not addressed for residents #24, #35, and #29 were written on Concern forms by NHA and given to appropriate manager for follow-up. This will be completed by 6/30/25. Step 2: Resident Council Minutes were audited back six months by NHA to ascertain any concerns not addressed on 6/30/25. Concern forms were completed and given to appropriate department manager for resolution. Step 3: LED, Life Enrichment staff, and all department managers will be educated by LNHA on proper follow-up of Resident Council concerns, i.e., proper documentation of the following: education provided, equipment needed, replacement of items, etc. This will be completed by 6/30/25. Step 4: To monitor and
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Resident rights were violated when the NHA and a maintenance employee searched a resident’s room and took his camera without his consent while he was away at an outing. The resident, who had pain and difficulty walking, said his belongings were searched without permission, and his roommate confirmed the event. The NHA later acknowledged the resident-rights concern.
Missing Personal Items Not Returned or Replaced: Two residents reported missing clothing and other personal belongings that staff had not resolved, and grievance records showed multiple complaints about missing items. Observation of the laundry area found unlabeled clothing, shoes, and blankets stored in carts and on shelves, while staff said items often accumulated without names, were not routinely delivered to residents, and were sometimes donated or redistributed.
Oxygen Concentrator Not Inventoried in Resident Property Record: A resident with CHF, OSA, and atrial fibrillation had an oxygen concentrator from home at the bedside, but it was not listed in the resident's clothing and possessions inventory. The resident said he used the concentrator himself when needed and that his belongings record had not been updated after returning from the hospital. The LVN and DON confirmed there was no documentation of the concentrator in the inventory or nursing notes.
A resident’s urinary catheter was repeatedly observed hanging from the bedframe and visible from the doorway. The resident said it bothered him/her that the Foley could be seen, and an LPN noted the catheter was not covered. The charge nurse stated it was likely a hospital Foley that had remained in place since the resident returned and should have been changed out or at least covered.
Failure to Address Resident's Facial Hair and Dignity: A resident with Parkinson's disease, dementia, and ADL self-care deficits was observed on multiple occasions with long facial hair on her upper lip and chin. She stated she wanted it shaved, said staff had not offered, and reported it made her feel like a man. The DON and an MDS LVN stated grooming includes offering hair removal when residents want it, and a CNA confirmed the facial hair was present.
Failure to provide dignified dining assistance: A resident with stroke, diabetes, and dementia, who had a BIMS score of 3 and was dependent on staff for meals, was served lunch in the dining room but did not receive help eating until 20 minutes after the tray was delivered. The RNS confirmed the delay, and the DON confirmed the facility failed to provide a dignified dining experience.
Resident room searched and camera confiscated without consent
Penalty
Summary
The facility failed to obtain consent before searching a resident’s personal possessions and room, and it confiscated the resident’s camera without the resident being aware of the search. Facility policy stated that residents have the right to a dignified existence and to retain and use personal possessions to the maximum extent space and safety permit. The Nursing Home Administrator reported that, after being told the resident had a camera in his room, he and a maintenance employee went to the resident’s room and searched it while the resident was away on a resident outing. The resident’s clinical record showed diagnoses including pain and difficulty walking. The resident stated that his roommate told him the NHA and maintenance employee searched his room and took his camera without permission, and he said he keeps his belongings bagged in drawers and the closet so no one goes through them. The roommate confirmed the room search occurred, and the NHA later acknowledged understanding the resident-rights concern related to searching the room without notifying the resident first and taking the resident’s personal property.
Missing Personal Items Not Returned or Replaced
Penalty
Summary
The facility failed to ensure residents’ right to retain and use their personal possessions for two residents with missing belongings. One resident in room 127W reported that staff had been told on several occasions that clothing, tennis shoes, and a blanket were missing; the resident stated the items had been labeled with the resident’s name using a black marker, but they were neither returned nor replaced. Another resident in room 111P also reported missing personal items to several facility staff members and had not received any resolution regarding the missing belongings. A review of the grievance log showed six grievances filed between 12/11/2025 and 05/01/2026 related to missing personal items, and the grievances documented that the residents’ items were neither returned nor replaced. During observation of the laundry room, several collections of clothing, shoes, and blankets without names were seen in a laundry cart, on a table near the dryers, and on a shelf; Staff A verified the items did not have name labels and said staff were unsure which residents they belonged to. The Social Services Director stated most grievances were related to missing items, and the Laundry Assistant said resident clothing was not delivered because resident linens and towels were the priority and unnamed clothing continued to accumulate in the laundry room. The Nursing Home Administrator stated unnamed clothing was donated about once per month, sometimes given to residents with fewer belongings, and occasionally taken to the activities room for residents to identify missing items.
Oxygen Concentrator Not Inventoried in Resident Property Record
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity by not ensuring the resident's oxygen concentrator was inventoried in the Resident's Clothing and Possessions record. The resident was admitted with diagnoses including heart failure, obstructive sleep apnea, and atrial fibrillation. The H&P indicated the resident had capacity to make decisions, and the MDS indicated the resident could make himself understood and understand others. During observation, the resident was seen in his room with an oxygen concentrator turned off at the right side of the bed with nasal cannula tubing attached. The resident stated he brought the concentrator from home, had used it for a long time, and could apply the tubing and turn it on himself when needed. He also stated he had asked if it was okay to bring it in and said no one had updated his personal belongings after he returned from the hospital. Record review showed the resident's chart contained no order for oxygen therapy administration or monitoring, while the Weights and Vitals Summary documented oxygen via nasal cannula on several dates. The LVN stated there was no mention of the oxygen concentrator in the nursing notes or the Resident's Clothing and Possessions form, and the DON stated the inventory should be updated on the day of admission or after admission. The DON also stated the inventory protects residents' property rights and helps prevent misappropriation of property.
Visible Foley Catheter Not Covered
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect when a urinary catheter was observed hanging from the bedframe and visible from the doorway on multiple observations. During interviews, the resident stated it bothered him/her that the Foley could be seen from the door. An LPN observed that the Foley was visible and not covered, and stated the facility’s Foley catheters normally have a cover attached and are usually changed on admission. The charge nurse stated it had likely been that way for a while because it was a hospital Foley rather than the facility’s, and that the resident had been back since the prior weekend but the catheter should have been changed out or at least covered.
Failure to Address Resident's Facial Hair and Personal Grooming Preference
Penalty
Summary
The facility failed to ensure Resident #51 was treated with respect and dignity by not ensuring her facial hair was addressed according to her preference. Resident #51 was admitted with diagnoses including Parkinson's disease, muscle weakness, lack of coordination, dementia, and anxiety. Her quarterly MDS documented that she was usually able to make herself understood, usually understood others, and had a BIMS score of 9/15, indicating moderate cognitive impairment. Her care plan identified an ADL self-care performance deficit related to dementia and Parkinson's disease and stated she required extensive assistance with personal hygiene care. Observations on 6/23/2026, 6/24/2026, and 6/25/2026 showed long facial hairs on her upper lip and chin. During interview, Resident #51 stated she wanted her upper lip and chin shaved, was not aware she had facial hair, and said staff had not offered to shave her. She stated the facial hair made her feel like a man and that she did not want facial hair. The DON stated facial hair should be offered to be shaved for both men and women by CNAs and that staff were to provide care and ensure it was in the care plan. A CNA confirmed the resident had long hairs on her upper lip and chin, and an MDS LVN stated grooming included hair removal if residents wanted it.
Failure to Provide Dignified Dining Assistance
Penalty
Summary
The facility failed to provide a dignified dining experience for one resident during lunch meal service in the main dining room. Resident R3 was admitted with diagnoses including stroke with left side weakness, diabetes, and dementia. The resident’s MDS indicated a BIMS score of 3, and Section GG showed the resident was dependent on staff for meals. The care plan also indicated the resident needed assistance with eating. During observation, 16 residents were seated for lunch and the first tray was served at 11:35 a.m. Resident R3’s tray was served at 11:45 a.m. At 11:55 a.m., the resident stated, “Can you help me?” Staff did not assist the resident to eat until 12:05 p.m., 20 minutes after the meal tray was delivered. The RNS confirmed the tray delivery time and the delay in assistance, and the DON later confirmed the facility failed to provide a dignified dining experience for Resident R3.
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