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F0550
D

Failure to Honor Resident's Right to Make Choices Due to Staffing Issues

Urbana, Illinois Survey Completed on 10-15-2025

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 cognitively intact resident who requires assistance with eating, oral hygiene, dressing, bed mobility, and transfers was not provided with the opportunity to exercise her right to make choices about her daily routine. The resident's care plan did not include any focus area, goal, or interventions related to her right to make her own choices. On the morning in question, the resident expressed a preference to get up earlier and eat breakfast in the dining room to socialize with other residents, but was instead served breakfast in bed due to reported staffing shortages. The resident stated that while she understood the staff were working hard, it had become the norm for her to eat breakfast in bed because of low staffing, which was not her preference. Staff interviews confirmed that there were not enough staff available that morning to assist all residents who wished to go to the dining room for breakfast. A CNA acknowledged that several residents who would normally eat in the dining room could not do so due to lack of staff, and that residents should be able to go to the dining room if they choose. The interim DON stated that the facility met regulatory staffing requirements but recognized that resident care requests should be honored and was aware of the staffing concerns on the resident's hall. The facility's failure to honor the resident's right to make choices about her daily routine, specifically regarding meal location and timing, was directly linked to staffing issues and lack of care plan interventions.

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