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:
Staff failed to honor a resident’s expressed preference to use a mounted doorbell instead of knocking before entering the room. The resident had PTSD and a history of trauma, and knocking was a known trigger. During observation, a CNA knocked, rang the doorbell, and opened the door while the resident was being interviewed, despite a posted sign requesting staff ring the bell and not knock. Interviews confirmed staff knew the resident’s preference and trigger.
Failure to maintain resident dignity and privacy during care: multiple residents reported CNAs used personal cell phones while assisting with showers, peri-care, and other care, including texting and talking in resident areas and during meals. A resident with stroke-related paralysis and severely impaired cognition was observed receiving wound care with the door open and the privacy curtain not pulled, allowing others to see into the room while the LPN provided care.
A resident who was dependent on staff for toileting and transfers, and who was frequently incontinent, was left in bed in only a sweatshirt and brief while crying after staff told her to stay in bed and pee her pants so they could clean her up later. The resident said this happened often and that her call light was frequently turned off. Staff interviews confirmed she should not have been told to remain incontinent, and the DON stated residents should never be told to be incontinent because it is a dignity issue.
A resident with a foley catheter was observed with the catheter bag hanging uncovered on the side of the bed while the room door was open. The resident had diagnoses including stroke-related hemiplegia/hemiparesis and UTI, and the care plan noted a foley catheter related to neurogenic bladder. CNA staff stated the bag should have been covered, and the DON acknowledged it was a privacy issue.
Failure to Maintain Female Residents' Dignity With Unwanted Chin Hair: Three female residents were observed with visible chin hair after showers, despite needing staff assistance with bathing and grooming. Two residents had severe cognitive impairment and one had moderate cognitive impairment; one resident said the hair bothered her and another said she was waiting for the beauty shop to shave it off. Family members stated the residents would not choose to have beards and that the unwanted chin hair caused embarrassment and affected dignity.
A resident with impaired cognition, incontinence, and a catheter for neurogenic bladder had his catheter drainage bag visible in the commons area and later from the hallway, with clear yellow urine showing. Staff, including therapy, the IP, and an RN, did not arrange privacy, and the bag was also hung facing out toward the room entrance. The DON stated staff were expected to keep the blue side of the bag facing the public to cover it and maintain dignity.
Staff Failed to Honor Resident’s Doorbell Preference
Penalty
Summary
The facility failed to ensure staff treated Resident #39 with dignity and respect by honoring the resident’s expressed preference for how staff announced themselves before entering the room. Resident #39 was admitted with diagnoses that included PTSD and frontal lobe and executive function deficit, and stated during interview that knocking on the door was a known trigger related to a history of trauma. The resident preferred that staff use the mounted doorbell instead of knocking when the door was shut for privacy. During observation, CNA #2 approached the resident’s room, knocked on the door, rang the mounted doorbell, and then opened the door while surveyors were interviewing the resident. The resident responded, “Not now, I’m busy,” and the CNA closed the door. A sign posted outside the room stated, “Pls. Ring the Bell, Don’t Knock! STOP,” and a doorbell was mounted next to the sign. Interviews with the ADON and CNA #9 confirmed staff were aware of the resident’s preference and that knocking was a known trigger, yet the observed practice did not follow the resident’s stated wishes.
Failure to Maintain Resident Dignity and Privacy During Care
Penalty
Summary
The facility failed to treat residents with respect, dignity, and privacy by allowing staff to use personal cell phones while providing care and by failing to maintain privacy during wound care for one resident. Twelve confidential residents stated that CNAs used personal cell phones while assisting with showers, providing care in resident rooms, and performing peri-care, and that staff also texted and talked on phones while walking in hallways, at nurses’ stations, and in the dining area during meals. The residents stated this occurred on every shift and made them feel embarrassed, concerned about the quality of care, and that their privacy was violated. During interviews, the DON and ADM stated staff should not use cell phones or earbuds while providing care and should keep phones in breakroom lockers. They stated residents should receive undivided attention and that staff were trained on resident rights, dignity, privacy, and cell phone use during orientation, ongoing education, and in-services. They also stated staff were monitored through rounds, and both acknowledged that cell phone use in resident care areas could violate privacy and reduce attention to care. Resident #7 was a male resident with a history of cerebral infarction, left-sided hemiplegia and hemiparesis, and urinary tract infection, and his MDS indicated severely impaired cognitive skills for daily decision making. During observed wound care, LVN D did not close the door or pull the privacy curtain around the resident, and two female residents were seen passing by and looking into the room while care was being provided. LVN D stated she had been trained to close the door and pull the curtain but did not do so because she was waiting for the CNA, and the DON and ADM stated they expected the door to be closed and the curtain pulled for privacy during resident care.
Failure to Preserve Resident Dignity During Toileting Assistance
Penalty
Summary
The facility failed to ensure dignified care for one resident who was dependent on staff for toileting and transfers, frequently incontinent of bowel and bladder, and had diagnoses that included dementia, diabetes, non-traumatic spinal cord dysfunction, depression, heart failure, and asthma. Her care plan directed staff to assist her with toileting, provide incontinence care, and offer toileting every 3 hours so she could remain free of skin breakdown and have her dignity respected. She was also documented as being able to verbally ask for toileting assistance and requiring extensive assistance with transfers and toileting needs. During an observation, the resident was found lying in bed wearing only a sweatshirt and an incontinent brief, with no pants and not fully covered by bedding. She was crying and stated staff told her she had to stay in bed and could not get up, and that they told her to pee her pants and they would clean her up in bed. She stated this happened all the time and that nursing assistants shut off her call light just about every day. While she was crying, a nursing assistant entered, said she was wet and needed to be cleaned up, told her not to cry, and then provided incontinent care. During interviews, staff acknowledged the resident should not be told to go in her pants or be encouraged to remain incontinent. One NA stated the resident was encouraged to stay in bed because staff were short and the NA had other residents to care for, and that the resident had asked to get up but was waiting because she required assistance of 2. Other staff stated the resident should never be told to just go in her pants, that residents should not be told to be incontinent, and that such statements were a dignity issue. The DON stated staff were expected to provide care when requested and never tell a resident to be incontinent because it was a dignity issue.
Uncovered Foley Catheter Bag Observed With Door Open
Penalty
Summary
The facility failed to ensure a resident was treated with dignity when Resident #3’s foley catheter bag was observed hanging on the side of the bed without a cover while the room door was open. Resident #3 was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side and a UTI, and his care plan documented that he had a foley catheter related to neurogenic bladder. The facility’s Promoting/Maintaining Resident Dignity policy stated that residents are to be protected and promoted in their rights and treated with respect and dignity. During interview, CNA #1 stated the catheter bag should have been covered since the door was open, and the DON stated she had never thought the catheter should have been covered in the room with the door open and acknowledged it was a privacy issue.
Failure to Maintain Female Residents' Dignity With Unwanted Chin Hair
Penalty
Summary
The facility failed to treat three residents with dignity and respect when each had visible chin hair that was not consistently removed after bathing. Resident #1, a female resident with moderately impaired cognition, was dependent on staff for toileting and required assistance with bathing. Her record showed she was showered on 06/02/26, but on 06/03/26 and again on 06/04/26 she was observed with several white, approximately one-inch-long hairs on her chin. During interview, she stated the hairs bothered her and said she was waiting for the beauty shop ladies to come because they usually shaved her chin hair off for her. She also stated CNAs never shaved her chin. Resident #37, a female resident with severely impaired cognition, was dependent or required partial/moderate assistance across all ADLs except eating and required one staff member to assist with bathing. Her record showed she received a shower on 06/02/26. On 06/03/26, she was observed multiple times lying in bed with several dark and light grey hairs sprinkled across her chin, approximately half an inch long. During interview, her family member stated she would not choose to have a beard and that when at home she used a trimmer to remove unwanted chin hair. The family member also stated CNAs shaved her chin when they showered her. Resident #44, a female resident with severely impaired cognition, Parkinson's disease, lack of coordination, and muscle weakness, was dependent across all ADLs except eating and required two staff members for bathing. Her record showed she was showered on 06/02/26. On 06/03/26 and again on 06/04/26, she was observed with long, white, curling hairs on both sides of her chin. During interview, she stated it bothered her to have chin hair and that she did not like it. She said she could shave her chin if she had a razor and stated CNAs had shaved her chin in the past, but she did not know why they had not done so lately. Her family member stated the chin hair bothered her, that he had never seen her with chin hair before she came to the facility, and that she would become emotional and embarrassed if it was mentioned.
Visible Catheter Drainage Bag Not Kept Private
Penalty
Summary
The facility failed to ensure dignity was maintained for one resident who had moderately impaired cognition, was dependent on staff for dressing, bed mobility, and toileting, was always incontinent of bowel and bladder, and had intermittent catheterization for neurogenic bladder. The resident’s care plan identified a catheter and included an intervention to position the catheter bag and tubing below the level of the bladder and away from the entrance room door. During an observation, the resident’s urinary catheter drainage bag was visible while he was seated in his wheelchair in the commons area, with clear yellow urine showing and the bag hung under the wheelchair. After the resident was brought to his room, staff emptied the catheter drainage bag and hung it on the side of the bed facing out to the room entrance. On a later observation, the catheter drainage bag was uncovered in the commons area, with the clear side facing toward the hallway and elevator space so that clear yellow urine was visible from the hallway. Therapy staff, the infection preventionist, and the resident’s RN were present in the area and did not arrange privacy for the catheter drainage bag. Staff later stated the bag should be covered for privacy, and the DON stated staff were expected to keep the blue side facing the public to cover the bag and maintain dignity. The facility’s dignity policy stated catheter drainage bags and colostomy pouches should be covered with commercial covers or tucked out of plain sight.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release August 26, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.