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F0557
D

Failure to Provide Dignified and Respectful Care During Overnight Shift

Hadley, Massachusetts Survey Completed on 09-16-2025

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

Two residents who were alert, oriented, and dependent on staff for care reported being treated in an undignified and disrespectful manner by a Certified Nurse Aide (CNA) during the overnight shift. Facility policy requires that residents be treated with respect and dignity, but both residents described the CNA as abrupt, rude, and failing to respect their wishes. One resident, with diagnoses including acute bronchitis and moderate dementia, alleged that the CNA used profanity and was rough during care, which was corroborated by the resident's cognitively intact roommate who overheard the incident and reported similar language and behavior. Another resident, with a history of osteoarthritis, chronic pain syndrome, diabetes, and major depressive disorder, was also dependent on staff for all activities of daily living and mobility. This resident reported that the CNA entered the room without explanation, began care abruptly, and ignored complaints of pain when moving the resident's leg, despite the care plan requiring assistance from two staff members for bed mobility. The CNA admitted to being agitated and acknowledged not following proper procedures, including attempting to move the resident alone and continuing care despite the resident's expressed pain. Interviews with the involved residents, a roommate, and a nurse confirmed that the CNA used harsh language, failed to communicate appropriately, and did not provide care in a manner that maintained the residents' dignity or respected their individual needs. The incidents were reported to nursing staff immediately after they occurred, and the facility's investigation documented the residents' accounts and the CNA's admission of inappropriate conduct.

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