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F0550
D

Resident Not Treated with Dignity After Being Left Outside

Marshalltown, Iowa Survey Completed on 08-05-2025

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

A resident with intact cognition, as indicated by a BIMS score of 14, and diagnoses including non-Alzheimer's dementia, anxiety, depression, and dizziness, was identified as being independent with activities of daily living. The resident's care plan included interventions related to tobacco use, such as completing smoking evaluations as needed, keeping smoking accessories secured, checking in and out, carrying a cell phone while smoking, and smoking only in designated areas or times. On one occasion, the resident was left outside all night and subsequently reported feeling degraded and disrespected after being told by the DON and Administrator that it was her responsibility to always have her cell phone to re-enter the facility. Interviews with the Administrator and DON confirmed their expectation that the resident should ensure she had her cell phone at all times to regain entry. The resident expressed that this made her feel blamed for the incident and led her to avoid going outside alone. The facility's policy on dignity and respect instructs staff to treat all residents with dignity and respect, maintaining and enhancing self-esteem and self-worth, and providing reasonable accommodation of individual needs. The actions and statements of the facility leadership did not align with this policy, resulting in a failure to treat the resident with the required respect and dignity.

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