Failure to Protect Resident Dignity, Call Light Access, and Dining Comfort
Summary
The facility failed to ensure residents were treated with dignity and respect when staff entered resident rooms without knocking or announcing themselves, failed to keep call lights within reach for some residents, and did not adjust the dining room temperature to a comfortable level for residents seated under cold air vents. These failures affected nine of 36 sampled residents in a census of 171. During observation and interview, a housekeeper entered one resident’s room while the resident was eating breakfast, opened the door without notice, and vacuumed while talking on a cell phone. The resident said staff do this all the time and never knock. In another room, a CNA entered without knocking while the resident was meeting privately with a surveyor, walked between the resident and surveyor, and did not acknowledge them. Two other residents reported staff entering their rooms without knocking or introducing themselves, including one resident who was startled when a CNA appeared beside the bed and another who was frightened when a man entered the room and went into the bathroom without notice. A resident with moderately impaired cognition, left-sided paralysis, chronic kidney disease, legal blindness, and urine retention was observed calling for help and repositioning assistance while in pain. The resident repeatedly used the call light and called out for help over several minutes, while a CNA entered without announcing herself, turned off the call light, said she would get help, and left the room. The resident continued crying and calling for assistance until the CNA returned later. In addition, call lights for other residents were repeatedly observed at the foot of the bed or otherwise out of reach, including one resident whose family said the issue had been brought to nursing staff and another resident who yelled for staff while the call light remained out of reach. The dining room temperature on the 400 hall was also observed to be cold on multiple occasions. Residents seated under ceiling supply vents said the room was too cold, and air measurements showed cold air blowing directly on the tables. One resident asked a CNA to adjust the temperature because he or she was too cold, but the temperature remained unchanged for hours. Residents stated the cold air made it difficult to enjoy meals because food cooled too quickly, and staff acknowledged that the vents blew directly down on the residents seated at those tables.
Penalty
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A resident with hemiplegia, hemiparesis, and vascular dementia was transferred in a mechanical lift from her room into a hallway to a reclining shower bed while only partially covered with a bath sheet, leaving her hips and buttocks exposed to others in the area. The resident said she did not like being left exposed, and staff stated the bed was usually placed outside her room because of space limits, though the DON expected her dignity to be preserved during the transfer.
A facility failed to provide a dignified dining experience for two residents who needed feeding assistance. One resident was left waiting while another resident at the same table was assisted and a third fed himself, and another resident received a tray but was not helped until staff finished assisting someone else at a different table. A nurse aide stated there were only two staff in the room and four residents who needed feeds.
Cell Phone Use During Resident Care: CNAs were observed by 11 confidential residents using personal cell phones while providing showers, peri-care, and other hands-on care, as well as while walking in halls, at the nurses’ station, and in the dining area. Residents said the phone use made them feel ignored, embarrassed, and that their privacy was violated. The DON and ADM stated staff should give residents full attention and not use cell phones in patient care areas, and the facility policy required residents be treated with kindness, respect, dignity, and confidentiality.
A PTA entered two residents’ shared room without knocking or announcing herself first. One resident had arthrogryposis multiplex congenita, tracheostomy dependence, and respirator dependence, and both residents had severely impaired cognitive skills and were dependent on staff for multiple ADLs. The PTA stated she should have knocked and introduced herself, and the DON said staff should knock and announce themselves before entering to respect residents’ dignity and rights.
A resident with quadriplegia and spinal stenosis missed a standing off-campus PT appointment after transport was not properly coordinated. A CNA escorted him to the pickup area, where Driver 1 said no driver was available and sent him back to his room, while Driver 2 later documented the trip as canceled without notifying the unit that she was available. RN staff did not verify transportation, and the resident became upset and reported feeling neglected and that his care was less important than other residents’ care.
A resident with moderate cognitive impairment, MS, neurogenic bladder, an indwelling catheter, and a left nephrostomy tube had his nephrostomy drainage bag left uncovered and visible from the hallway while seated in a Broda chair with his room door open. The care plan directed staff to ensure he was appropriately covered and dignity was provided, and the RNCM and DON confirmed the uncovered bag was a dignity concern.
Failure to Preserve Resident Dignity During Shower Transfer
Penalty
Summary
The facility failed to maintain Resident #67’s dignity during a shower transfer when two nurse aides moved her in a mechanical lift from her room into the common area hallway to a reclining shower bed on the other side of the hall. Resident #67 had diagnoses including hemiplegia, hemiparesis following cerebral infarction affecting the right dominant side, and vascular dementia. Her quarterly MDS indicated she was severely cognitively impaired, required a wheelchair for mobility, was dependent on staff for transfers, dressing, and bathing, and had a care plan that included assistance with positioning, transfers, toileting, personal hygiene, and bathing as needed. During continuous observation, NA #1 and NA #2 transferred Resident #67 with a bath sheet covering the front of her nude body, but her bare hips and the bare sides of her buttocks were exposed while she was moved through the hallway. Other staff members and residents were present in the hallway during the transfer. Resident #67 later stated that the nurse aides would cover the front part of her body with a sheet and leave her sides exposed, and that she really did not like that. Her care plan also addressed behavioral symptoms, including undressing with the door open, refusing care, crying, and cursing, and included providing an appropriate level of privacy. The nurse aides stated they usually placed the reclining shower bed right outside Resident #67’s room because there was not enough room to place both the mechanical lift and the bed inside the room. NA #1 said the bed had been moved across the hall on the observed occasion and that they typically would not push the lift across the hall. NA #2 stated her normal process was to undress Resident #67 in bed and cover her with a shower sheet before transfer, and she did not realize Resident #67 was exposed. The DON later observed that the mechanical lift fit between the beds in the room, but the reclining shower bed barely fit at the foot of the bed and could not safely be used inside the room due to space constraints. The DON and Administrator stated they expected staff to preserve Resident #67’s dignity and ask about her shower preference.
Failure to Provide Dignified Dining Assistance
Penalty
Summary
The facility failed to provide a dignified dining experience for two residents, R16 and R118. The facility policy on feeding indicated that residents are to be fed in a therapeutic and dignified manner. During an observation in the dining room, R16 was seated at a table with two other residents, one of whom was being assisted with a meal by a nurse aide while the other fed himself, but R16 was not fed until the other resident was finished at about 12:05 p.m. During the same observation, R118 had received his tray while staff continued passing trays in the dining room, and he was seated with another resident who fed himself, but R118 was not assisted with his meal until 12:05 p.m., after a registered nurse finished assisting another resident at a different table. A nurse aide stated that there were only two staff in the room and four residents who needed feeding.
Cell Phone Use During Resident Care
Penalty
Summary
The facility failed to treat residents with respect, dignity, and care in a manner that promotes quality of life for 11 of 11 confidential residents when CNAs used personal cell phones while providing care. Residents stated that CNAs were on their phones during showers, peri-care, care in resident rooms, while walking in hallways, at the nurses’ station, and in the dining area during meals, including talking and texting through earpieces while care was being provided. The residents said this made them feel ignored, not a priority, embarrassed, and concerned that the CNA could make a mistake because of distraction, and they stated their privacy was violated. During interviews, the DON and ADM stated residents should receive privacy, full attention, and dignity during care, and that cell phones should not be used in patient care areas but only in the break room or during breaks. They also stated staff were trained on resident rights, dignity, privacy, and cell phone use during orientation and ongoing education, and that rounding was used to monitor compliance. The facility policy titled Resident Rights stated employees shall treat residents with kindness, respect, and dignity and protect privacy and confidentiality.
Failure to Knock Before Entering Residents’ Room
Penalty
Summary
The facility failed to provide care in a manner that promoted and maintained residents’ rights for two sampled residents when Physical Therapy Assistant 1 entered their shared room without knocking or announcing herself first. During an observation on 6/30/2026 at 3:45 p.m., PTA 1 was seen entering the room without knocking or introducing herself. In an interview immediately afterward, PTA 1 stated she did not knock or introduce herself before entering and said she entered to see whether Resident 2 was in the room. She also stated she should have knocked and introduced herself out of respect for the residents and to uphold their rights. Resident 2’s admission record showed diagnoses including arthrogryposis multiplex congenita, tracheostomy dependence, and respirator dependence, and the MDS dated 6/1/2026 indicated severely impaired cognitive skills for daily decision making and dependence on staff for oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, and mobility. Resident 3’s admission record showed a diagnosis of shaken infant syndrome, and the MDS indicated severely impaired cognitive skills for daily decision making and dependence on staff for oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, and mobility. The DON stated that all staff should knock and announce themselves before entering residents’ rooms, and the facility policy stated residents are to be treated with consideration, respect, and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs.
Missed Off-Campus Appointment Due to Poor Transportation Coordination
Penalty
Summary
The facility failed to accommodate a resident’s right to access services outside the facility when transportation for an off-campus medical appointment was not properly coordinated. The resident was admitted with diagnoses including quadriplegia, acromegaly and pituitary gigantism, and spinal stenosis. He had a standing appointment twice a week at an off-campus specialty clinic for physical therapy related to spinal injuries, and he had a scheduled pickup time of 10 a.m. for an 11 a.m. appointment. On the day of the appointment, a CNA escorted the resident to the pickup location, where Driver 1 told them he was the only driver and could not take the resident because he was assigned to residents going to appointments within the local campus. The resident was then escorted back to his room. The resident stated he was not told that another driver was available and later learned that Driver 2 had been available if he had remained downstairs. Driver 2 documented the appointment as canceled, stated she did not call the unit to notify staff she was available, and did not confirm with anyone that the appointment had been canceled. RN 1 stated the resident and CNA 1 told her there was no driver available, but she did not check for a driver or help coordinate transportation. Driver 1 stated he did not tell them another driver was coming because he did not know when the other driver would arrive. The resident’s care plan identified a risk for emotional distress related to lack of transportation to physical therapy appointments and included nursing coordination with transportation staff. Social work notes documented that the resident appeared unhappy and resigned after being told there was no driver, and he reported feeling neglected and that other residents’ care was more important than his.
Uncovered nephrostomy bag visible from hallway
Penalty
Summary
The facility failed to maintain a resident's dignity when R5's nephrostomy drainage bag was left uncovered and visible from the hallway. R5's quarterly MDS identified moderate cognitive impairment, need for assistance with ADLs, multiple sclerosis, neurogenic bladder, and an indwelling catheter. The care plan dated 6/1/26 identified R5 as incontinent of bowel and bladder related to multiple sclerosis and decreased mobility, and noted a left nephrostomy tube due to kidney stones and a Foley catheter. The care plan directed staff to provide incontinence care, monitor for signs and symptoms of a UTI, empty the left nephrostomy as ordered, and ensure R5 was appropriately covered and dignity was provided. During an observation on 7/1/26 at 12:42 p.m., R5 was seated in a Broda wheelchair in his room with the door open to the hallway, and the nephrostomy drainage bag was hanging uncovered from the left armrest of the chair and visible from the hallway. During a later observation and interview, a TMA stated the bag was usually hung on the armrest of R5's wheelchair. The RNCM and DON later confirmed the nephrostomy drainage bag was not covered and was visible from the hallway, and stated it should have been covered because the uncovered bag was a dignity concern.
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