F0550

E

Failure to Ensure Resident Dignity and Respect in Daily Care and Staff Interactions

West Frankfort, Illinois Survey Completed on 01-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure residents were treated with dignity and respect and that their input was valued, particularly in relation to staff attitudes, responsiveness, and thoroughness of care. Multiple residents with intact or moderately impaired cognition reported that CNAs, especially on the night shift, displayed “nasty” or exasperated attitudes when residents requested assistance. One resident with multiple medical conditions, including muscle wasting, lymphedema, venous insufficiency, and spinal stenosis, stated that a night CNA did not clean him adequately after incontinence episodes, wiping only the front and not further down despite his explanation that urine runs down due to gravity. Another resident with fractures, an artificial hip joint, and severe protein-calorie malnutrition reported that a male night CNA acted exasperated when she requested care, sometimes wiped her with a used brief, and did not adequately clean her when she had stool related to medication side effects.

Several other residents with diagnoses such as anxiety, depression, COPD, diabetes with neuropathy, osteoporosis, epilepsy, dementia, and chronic pain described CNAs as snappy, short, rushed, or not always nice, with particular emphasis on evening and night shifts. Residents reported that call lights could take a long time to be answered, sometimes 45 minutes to an hour at night, and that staff would say they would return but often did not. One cognitively impaired resident, alert to situation at the time of interview, stated that some staff were not nice or gentle and that they did not return after saying they would, and that a recent request for ice was denied with the explanation that they were out. Another resident stated that staff were often too busy on their phones to pay attention and specifically identified a CNA who lacked patience with certain residents, noting that some residents “have nothing else” and need staff to be patient.

Residents also reported issues with dietary and ancillary staff interactions that affected their sense of dignity and respect. One resident’s written concern described drinks not being made available until late in the afternoon despite repeated requests, leading residents to feel they were “making them mad” by knocking on the door. Another resident’s written complaint stated that the menu was posted late and too high to read, and that a kitchen worker became angry when asked for ice and told the resident to obtain it from a locked break room, causing the resident to stop asking for drinks due to staff reactions. Additional residents reported that kitchen staff were unhappy when residents knocked to request substitutes, that they sometimes had to knock multiple times because staff would not answer, and that night staff would not provide items such as milk. Multiple residents stated that concerns about staff attitudes, roughness, and rushing of more fragile residents had been discussed among residents and, at times, in resident council, although recent council minutes did not reflect these concerns. Facility leadership and some staff reported being unaware of poor staff attitudes, and resident council minutes documented few or no complaints about nursing, despite residents’ statements that they had raised these issues previously.

The facility’s own Employee Standards of Conduct document, dated 07/2024, states that the company expects each employee’s conduct and performance to conform with the highest standards of professionalism in the treatment of residents, visitors, and families, and to comply with applicable laws and regulations. However, the resident interviews and written complaints describe repeated instances where staff behavior—such as exasperated responses, refusal or reluctance to provide requested care or beverages, inadequate cleaning after incontinence, delayed call light response, and visible irritation when residents requested information or substitutes—did not align with these standards. The DON stated she was not aware of poor CNA attitudes, and a CNA reported not having seen staff display attitudes with residents, which contrasts with the multiple resident accounts of disrespectful or dismissive interactions. These findings collectively demonstrate that the facility did not consistently maintain residents’ rights to dignity, respect, and self-determination in daily care and communication.