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F0557
D

Resident Not Treated with Dignity by Activity Aide

Palmer, Massachusetts 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 resident with severe cognitive impairment and total dependence on staff for care was not treated with dignity and respect by an activity aide. The aide, in the presence of other residents and staff, used his fingers to jiggle the loose skin under the resident's neck while laughing and repeatedly calling the resident's name. This action was witnessed by another activity aide, who immediately told the aide to stop and described the behavior as rude. Additional staff members were aware of the incident, with one hearing the aide make a comment and begin playing with the resident's neck, and another hearing the admonishment that the behavior was not funny. The resident involved had a diagnosis of unspecified dementia with associated anxiety, restlessness, and agitation, and was unable to be interviewed due to severe cognitive impairment. The incident took place in the facility's dining/activity room, where several residents and staff were present. The aide involved later stated that he intended to be playful and did not perceive his actions as inappropriate, but acknowledged tickling the resident's neck skin. The incident was reported to the activity director and subsequently to the DON, who initiated an internal investigation. Facility policies reviewed by surveyors clearly stated that residents are to be treated with dignity and respect at all times, and that demeaning practices are prohibited. The actions of the activity aide were found to be in violation of these policies, as the resident was subjected to undignified treatment in a public setting, witnessed by both staff and other residents.

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