Failure to Treat Cognitively Impaired Resident With Dignity and Respond to Repeated Requests for Help
Summary
The deficiency involves the facility’s failure to treat a cognitively impaired resident with dignity and respect and to respond appropriately to his repeated requests for assistance. The resident had acute on chronic congestive heart failure, cardiomyopathy, pneumonia, unspecified dementia, anxiety disorder, and urinary retention, and was admitted with a Foley catheter. Assessments and therapy notes documented moderate to severe cognitive impairment, poor orientation, poor recall, confusion, and frequent yelling out for help or for his wife. Care plans identified behavior problems related to impaired cognition, including yelling out instead of using the call light, and directed staff to anticipate and meet needs, provide positive interaction, explain procedures, identify triggers, and use calm approaches and redirection. Multiple clinical notes from nursing, therapy, psychiatry, neurology, and pulmonary providers documented ongoing confusion, anxiety, constant yelling, inability to verbalize needs, and repeated pulling on the Foley catheter. On the morning of the incident, video footage and surveyor observations showed the resident seated in a gerichair in front of the nurses’ station with a Foley catheter bag attached to the chair and no call light or call bell available. From shortly after 6:00 a.m. onward, the resident repeatedly yelled for help, requested to use the bathroom, and asked for water and to call his family. Staff responses were intermittent and did not address his toileting requests; one staff member told him he had a catheter and did not assist him to the bathroom, another told him to remain reclined until breakfast, and others walked past without responding while he continued to call out loudly dozens of times. When he reported having had a bowel movement, he was told to wait until staff could be found, and no one assisted him with toileting or changing for an extended period. Staff also told him there was no reason for his yelling, that he was waking everybody up, and that it was too early to call his family, without addressing his expressed needs. Later that same morning, with no staff nearby, the resident attempted to stand and walk unassisted while still connected to the Foley catheter bag attached to the gerichair. As he took small, unsteady steps, the catheter tubing became taut and ultimately the catheter balloon and tubing were observed on the floor after being pulled out, and the resident yelled out loudly in pain. A CNA then approached and, without reassuring the resident or explaining her actions, grabbed his arm with both hands and attempted to pull him back toward the chair while he said “No” and tried to walk in the opposite direction. The CNA then positioned the gerichair in front of him and repeatedly ordered him in a rude, firm tone to “sit down here” and “sit in there,” without explanation, while the resident questioned what the chair was. During toileting assistance in the bathroom, the CNA’s firm and rude tone continued, and the resident was overheard asking her not to be rude. Interviews with staff and leadership confirmed awareness of the resident’s ongoing yelling behaviors and confusion, and the facility’s own policy required that residents be treated with kindness, respect, and dignity and be free from abuse and neglect, which was not followed in this case. The facility’s care plans and provider recommendations called for consistent routines, environmental modifications, structured activities, task segmentation, frequent redirection, and calm, respectful communication to address the resident’s impaired cognition and behaviors. Despite this, there was no evidence of updates or revisions to the behavior-related care plan interventions after mid-December, even as documentation showed escalating yelling, anxiety, and inability to be redirected. On the day of the incident, staff did not implement the planned interventions such as anticipating and meeting needs, providing one-to-one interaction, or promptly assisting with toileting, and instead left the resident unattended in the hallway for prolonged periods while he loudly and repeatedly called for help, the bathroom, water, and his family. The combination of failing to respond to his expressed needs, leaving him without a call system or supervision despite known impulsivity and unsteady gait, and interacting with him in a rude and non-reassuring manner constituted a failure to honor his rights to dignity, respect, self-determination, and communication as outlined in the facility’s resident rights and dignity policy. Other residents and staff interviews corroborated that the resident frequently screamed and that he likely wanted someone to talk to or an activity to calm him. CNAs and nurses described appropriate approaches they would generally use for confused, yelling, or restless residents, such as sitting with them, holding their hand, providing activities, or placing them near the nurses’ station with close supervision. However, on the morning in question, these approaches were not consistently applied to this resident. The Director of Nursing acknowledged awareness of his yelling and impulsivity and stated expectations for calm approaches, redirection, and offering comfort measures, while the Administrator acknowledged that staff could have done a better job addressing his requests to use the bathroom. The documented events, observations, and interviews collectively show that the resident’s rights to be treated with dignity and respect and to have his needs assessed and addressed were not upheld. The facility’s written policy on Resident Rights/Dignity required employees to treat all residents with kindness, respect, and dignity and guaranteed residents the right to a dignified existence, to be treated with respect, kindness, and dignity, to be free from abuse and neglect, and to exercise self-determination and communication with people and services. The observed failure to respond to the resident’s repeated requests for toileting and assistance, the lack of a call light, the prolonged periods without staff attending to him while he yelled for help, and the CNA’s rude tone and physical handling of his arm were inconsistent with these policy requirements. These actions and inactions formed the basis of the cited deficiency for failure to ensure the resident was treated with dignity and respect.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to maintain resident dignity was identified when three residents with indwelling urinary catheters had drainage bags hanging on the bedframe without privacy covers, despite physician orders for privacy covers every shift. In addition, a resident who was ordered to be fed by staff was observed being fed by a nurse aide standing beside the bed during lunch, and the DON confirmed the dining experience was not dignified.
A resident with dementia, anxiety, and osteoarthritis was observed sitting naked on the bed in full view of the hallway while a CNA assisted with dressing. The care plan directed staff to assist with dressing, and the CNA stated the curtain had not been pulled after returning the resident from the bathroom. The ED confirmed the facility failed to maintain the resident's dignity.
Failure to provide a dignified dining experience: Four residents with significant diagnoses, including Parkinson’s disease, schizophrenia, cerebral palsy, TBI, and dysphagia, were brought to the assistive dining room for lunch but were not served their trays until more than 50 minutes after the posted mealtime. While other residents were already being assisted with eating, these residents were left watching the meal service, and the DON stated they should have been served at the same time as the others or not brought in until their trays were ready.
A facility failed to protect the dignity of two residents when an LPN administered insulin injections in the commons area in full view of surveyors, staff, and other residents. The LPN lifted each resident’s shirt, cleansed the injection site, and gave the subcutaneous insulin injection publicly rather than in a private area.
A resident with dementia, depression, and anxiety was seated in the dining room while other residents ate, but the lunch tray was not served with the group on two occasions. In a separate event, an LVN administered oral meds to another resident with intellectual disability and cerebral palsy in the dining room while wearing gloves, rather than in a private setting, which staff stated was not the facility’s practice and could be seen as disrespectful.
A resident with dementia and Alzheimer's disease had his beard completely shaved by two CNAs without his RP's consent. The RP stated the resident had worn his beard for many years and had not been seen without it, and the DON stated the RP should have been notified because the resident lacked capacity to make decisions for himself. The facility policy required staff to ask the resident or, when appropriate, the resident representative about grooming preferences upon admission.
Failure to Maintain Resident Dignity During Catheter Care and Dining
Penalty
Summary
The facility failed to maintain resident dignity by not ensuring privacy covers were applied to urinary catheter drainage bags for three residents. Resident R26, who had diagnoses of diabetes, high blood pressure, and coronary artery disease, had a physician order for catheter care to provide a privacy cover for the drainage bag every shift. During observation, the catheter drainage bag was hanging on the bedframe without a privacy cover. Resident R178, with diagnoses of diabetes, high blood pressure, and depression, also had an order for a privacy cover every shift, and the drainage bag was observed hanging on the bedframe without a privacy cover. Resident R179, diagnosed with COPD, atrial fibrillation, and heart failure, likewise had an order for a privacy cover every shift, and the drainage bag was observed hanging on the bedframe without a privacy cover. An RN confirmed that the bags should be covered and that the residents' dignity was not maintained. The facility also failed to provide a dignified dining experience for one resident who was ordered to be fed by staff. Resident R39, who had diagnoses of high blood pressure, heart failure, and diabetes, had a care plan and physician order for staff to feed all meals. During lunch observation on the 2B nursing unit, the resident was sitting upright in bed while a nurse aide stood beside the bed feeding the resident. The nurse aide stated that they should have been sitting down while feeding but did not know where the resident's chair was. The DON later confirmed that the facility failed to provide the right to a dignified dining experience for one of two lunches observed on 2B.
Failure to Maintain Resident Dignity During Dressing Assistance
Penalty
Summary
The facility failed to provide care and services to maintain a resident's dignity for one of 11 sampled residents. Resident R23 had diagnoses including dementia, anxiety, and osteoarthritis. The MDS dated [DATE] indicated the resident had mild cognitive impairment and required assistance with dressing. The care plan identified a self-care performance deficit related to dementia and directed staff to assist the resident with dressing. During observation on 8/4/2026 at 10:15 a.m., Resident R23 was sitting on the bed naked in full view of anyone walking by in the hallway while a CNA was assisting with dressing. During interview, the CNA stated that the curtain had not been pulled after bringing the resident back from the bathroom, and the Executive Director confirmed the findings and that the facility failed to provide care and services to maintain the resident's dignity.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect for 4 of 8 residents reviewed for respect and dignity. The facility’s Assistance with Meals policy stated that staff will serve resident trays and help residents who require assistance with eating, and that residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity. The facility’s Dignity policy stated that each resident shall be cared for in a manner that promotes and enhances well-being, satisfaction with life, and feelings of self-worth and self-esteem, and that residents are supported in exercising their rights during care. Resident #4 had diagnoses including Parkinson’s Disease and major depressive disorder. Resident #13 had diagnoses including schizophrenia and abnormal involuntary movement. Resident #19 had diagnoses including spastic quadriplegic cerebral palsy and anxiety disorder. Resident #44 had diagnoses including traumatic brain injury and dysphagia. During observation of the assistive dining room during the lunch meal, eight residents were present and only four were being assisted with eating after their meals had been delivered. Residents #4, #13, #19, and #44 were not served their lunch trays until after 12:10 PM, more than 50 minutes past the posted lunch mealtime, and were observed watching other residents who were already being assisted with their meals. The DON stated these residents should have been served at the same time as the other residents or not brought into the dining room until their trays were ready.
Failure to Protect Resident Dignity During Insulin Administration
Penalty
Summary
The facility failed to provide care for R4 and R1 in a manner that protected and promoted their dignity. On 08/04/2026 at 07:32 AM, observation in the commons area showed LN G pulling up R4's shirt on his left arm, cleansing the area with an alcohol wipe, and administering a subcutaneous insulin injection in his right upper arm while two surveyors, multiple facility employees, and numerous other residents could view the procedure from the four halls and dining room area. On 08/04/2026 at 07:40 AM, a similar observation in the commons area showed LN G pulling up R1's shirt on his left arm, cleansing with an alcohol wipe, and administering a subcutaneous insulin injection in his right upper arm in full view of two surveyors, multiple facility employees, and numerous other residents. On 08/05/2026 at 08:10 AM, Administrative Nurse D verified that LN G should not administer insulin injections in public areas and that residents should be taken to their rooms or a private area. The facility's Respect and Dignity; Right to Personal Property policy, dated August 2026, stated residents have the right to be treated with respect and dignity.
Late Meal Service and Public Medication Administration
Penalty
Summary
Facility staff failed to promote dignity and respect for Resident 3 when the resident’s lunch tray was not served with the other residents in the dining room on 7/30/2026 and again on 7/31/2026. Resident 3 was admitted with diagnoses including dementia, major depressive disorder, and anxiety, and the MDS indicated the resident had moderately impaired cognitive skills for daily decision making and required supervision or substantial assistance with multiple activities of daily living. During observation, Resident 3 was seated at a dining table with other residents while the other residents were eating, but Resident 3 had no lunch tray present. During the first observation, Treatment Nurse 1 verified that Resident 3 had no lunch tray and was watching the other residents eat, and stated he did not know why the tray was not included with the others. The Assistant DON later stated the resident was not served lunch on time and should have been served between 12:00 PM and 12:15 PM with the other residents in the dining room. On the second day, Resident 3 was again observed seated at the dining table at 12:15 PM with no lunch tray while other residents were eating. The DON and Dietary Supervisor stated the delay left the resident waiting while others ate, and the Dietary Supervisor stated the system for getting the dining room resident list to the kitchen staff was not working. Facility staff also failed to maintain Resident 4’s dignity during medication administration in the dining room. Resident 4 was admitted with diagnoses including mood disorder, intellectual disability, and cerebral palsy, and the MDS indicated the resident required substantial assistance with several activities of daily living. During observation, LVN 1 administered oral medication to Resident 4 in the dining room while wearing gloves. Treatment Nurse 1 stated medication should not be given in a public area and that the resident should have been assisted back to the room for private medication administration. The DON stated the resident could feel disrespected and that other residents might think the resident had an infectious disease because staff wore gloves while giving the medication.
Unauthorized Shaving of Resident's Beard
Penalty
Summary
The facility failed to ensure that two CNAs did not shave the beard of one resident without the resident's RP's consent. The resident had diagnoses including dementia and Alzheimer's disease, and his MDS indicated his cognition was moderately impaired and that he was dependent on facility staff for ADLs. The resident's RP stated that the beard was shaved without her knowledge or consent and that the resident had worn his beard for many years and she had never seen him without it. The DON stated that the RP should have been notified before the resident's beard was shaved because the resident did not have capacity to make decisions for himself. The DON also stated that CNA 1 and CNA 2 reported the resident looked unkempt and dirty on admission and that they felt he needed grooming. The facility policy on resident preferences stated staff should ask the resident and, when appropriate, the resident representative about preferences upon admission before initiation of treatment/therapy and/or during the initial IDT meeting, including preferences related to grooming.
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