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F0550
E

Failure to Ensure Resident Dignity and Respect During Care

Indianola, Iowa Survey Completed on 12-02-2025

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

The facility failed to ensure that residents were treated with dignity and respect, resulting in two separate incidents involving two residents with intact cognitive status and significant care needs. In the first incident, a resident requiring maximal to dependent assistance for daily activities and with diagnoses including non-Alzheimer's dementia and Parkinson's was subjected to verbal abuse by a Certified Nurse Aide. The aide, during care related to incontinence, responded to the resident's complaints of pain by yelling profanities and telling the resident to "shut the fuck up." This interaction was overheard by a housekeeping staff member, who reported it to nursing leadership. The resident did not recall the incident during a subsequent interview. In the second incident, another resident with multiple chronic conditions and moderate assistance needs was subjected to harsh treatment by an LPN during the overnight shift. The LPN was observed standing in the doorway, yelling at the resident to stay in bed while the resident was crying. The lights were off in the room, and the resident's oxygen cannula was not in place, resulting in blue lips. The aide who discovered the situation noted that the LPN was known for being rude and unhelpful, and the resident later reported feeling bossed around and upset by the nurse's behavior. The resident described the nurse as acting "like a soldier" and using inappropriate language. Both incidents were corroborated by staff interviews and resident statements, indicating a pattern of staff failing to provide care in a manner that maintains or enhances residents' dignity and quality of life. The affected residents were observed to be alert and pleasant during follow-up interviews, but both had experienced distressing interactions with staff that did not honor their rights to respectful and dignified treatment.

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