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F0550
D

Failure to Treat Residents with Dignity and Respect During Care

Saint Peters, Missouri Survey Completed on 11-25-2025

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

Staff failed to treat two residents with dementia and Alzheimer's disease with dignity and respect during the provision of care. In both cases, certified nurse aides (CNAs) did not greet or explain care to the residents, who had significant cognitive impairments and were dependent on staff for activities of daily living. The CNAs used forceful and disrespectful language, exposed the residents unnecessarily, and did not follow the care plans that required clear communication and anticipation of the residents' needs. For one resident, video footage showed a CNA using a mechanical lift to transfer the resident to bed without any greeting or explanation. The CNA removed the resident's clothing, left the resident exposed, and used a scolding tone, repeatedly telling the resident to comply and threatening to call a doctor for a sedative. The CNA also made inappropriate comments about sending the resident out if they did not cooperate. The resident, who was unable to make decisions and had impaired communication, showed resistance, which was misinterpreted by the staff as defiance rather than a lack of understanding. In the second case, another CNA entered a resident's room, turned on the light, and began providing care without speaking to or explaining actions to the resident. The CNA pushed the resident, removed blankets despite the resident's protests, and engaged in an argumentative and mocking exchange. The resident became visibly upset, used foul language, and attempted to defend themselves physically. The CNA continued to provide care in a hostile manner, laughed at the resident, and made dismissive comments, further escalating the resident's distress. Both incidents were captured on video and reported by family members.

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