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F0550
D

Failure to Maintain Resident Dignity and Respect During Care and Meals

Jefferson, Wisconsin Survey Completed on 06-23-2025

Penalty

10 days payment denial
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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

Multiple deficiencies related to resident dignity and respect were identified during surveyor observations and interviews. One resident with an indwelling urinary catheter was repeatedly observed without a privacy cover on the catheter drainage bag, both in her room and in common areas, making the bag visible to others. Despite care plan interventions specifying the use of a privacy cover and staff acknowledging the requirement for such covers, the resident's catheter bag remained uncovered on several occasions. The resident herself confirmed that the drainage bag was not always covered when she moved throughout the facility. Additional deficiencies were observed in the dining area involving two other residents. One resident with severe cognitive impairment and a diagnosis of dementia was seen sleeping with her head in her lap at the dining table, with food scattered around her bowl and no staff present to assist. Later, a CNA was observed feeding this resident while standing over her, contrary to facility training that requires staff to sit at eye level with residents during feeding to maintain dignity. The resident was also noted to lack adaptive utensils recommended by occupational therapy. Another resident, who was completely dependent on staff for eating due to severe cognitive and physical impairments, was referred to as a "feeder" by staff calling across the dining room. This resident was also left alone at a table with food placed in front of her, despite being unable to feed herself. Staff interviews confirmed that this was not appropriate and did not align with facility policies or training on maintaining resident dignity and respect.

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