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F0550
D

Failure to Provide Timely Toileting Assistance and Maintain Resident Dignity

Mount Zion, Illinois Survey Completed on 12-16-2025

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

A deficiency occurred when a staff member failed to provide timely toileting assistance to a resident who was cognitively intact and typically continent of bowel and bladder, but required substantial assistance for transfers. The resident requested to be taken to the bathroom before breakfast, but the Certified Nursing Assistant (CNA) delivering the meal tray refused, stating she was not assigned to the resident and was too busy, and told the resident to urinate in her incontinence brief. As a result, the resident was left sitting in urine for an extended period, which caused her significant emotional distress and humiliation. The incident was corroborated by the resident's roommate and another CNA, both of whom confirmed the resident's upset state and the inappropriate response from the staff member. Further interviews with staff revealed that the CNA responsible for delivering trays did not assist the resident or ensure that another staff member promptly addressed the toileting request. The resident's incontinence brief was found to be dry when she was later assisted to the bathroom, confirming her usual continence when toileted in a timely manner. The facility's policy requires all staff to treat residents with dignity and to respond to their needs regardless of assignment, but this was not followed in this instance, resulting in a failure to maintain the resident's dignity and respect.

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