Failure to Respond Timely to Call Lights Resulting in Prolonged Incontinence and Loss of Dignity
Summary
The deficiency involves the facility’s failure to honor residents’ rights to timely care and dignified treatment by not responding promptly to call lights, particularly on the North Hall. Multiple cognitively intact or moderately impaired residents who were dependent on staff for toileting and repositioning reported extended delays, often 30–60 minutes, before staff responded to their requests for assistance. These delays occurred despite care plan interventions that emphasized keeping call lights within reach and encouraging residents to use them for help, as well as documentation that several residents were incontinent and required extensive or total assistance with ADLs and toileting. One resident with chronic respiratory failure, type 2 diabetes, morbid obesity, chronic kidney and heart disease, and a history of moisture-associated skin damage reported that on an evening shift she waited over 30 minutes for her call light to be answered, and that such delays of 30 minutes to an hour happened frequently, especially in the evenings. This resident was bedbound, dependent on staff for toileting and repositioning, always incontinent of bowel, and at risk for impaired skin integrity, yet she reported that often only one CNA was assigned to her hall and one CNA to the other hall. Another resident with Parkinson’s disease, COPD, panic disorder, and fibromyalgia, who required assistance with ADLs and was occasionally incontinent, stated she had to wait over an hour on an evening shift for her call light to be answered while lying in a soaked bed and feeling cold from being in her urine. She reported that when still in her wheelchair, she would sometimes wheel into the hall to look for staff because of the delays. A third resident with permanent atrial fibrillation, chronic respiratory failure, type 2 diabetes, unsteadiness on feet, and chronic pain, who was always incontinent and dependent for toileting hygiene, stated she had her call light on several times one night and had to wait 30–45 minutes each time for staff to respond, during which she lay in urine while waiting to be changed. A fourth resident with hemiplegia, type 2 diabetes, COPD, morbid obesity, neurocognitive disorder with Lewy bodies, dementia with behavioral disturbance, Parkinson’s disease, and multiple other comorbidities, who was always incontinent and dependent for toileting and transfers, reported being on her call light for over 30 minutes one night, even calling the nurses’ station for help, while waiting to be changed after an incontinent episode. She stated that such delays in the evening occurred often and that it could take 30–45 minutes, sometimes an hour, for call lights to be answered. Surveyor observations and staff interviews corroborated these reports of delayed responses. On one evening, the DON stated that only two CNAs were working the floor, one CNA had called in, another had not shown up or called, and an agency nurse unfamiliar with the facility was the nurse on duty. The DON also stated another CNA was coming in later to help. During this time, the CNA assigned to the North Hall was observed taking residents outside to smoke, leaving no other CNA visible on that hall. Multiple call lights were observed activated in four separate rooms on the North Hall for an extended period while the CNA was outside and then occupied with other tasks, including taking vital signs on a resident in the dining room and answering the phone. An unknown resident was heard yelling for help from the North Hall while call lights continued to sound. The Administrator later stated he felt staff answered call lights in a timely manner but acknowledged that if only one CNA was on a hall, that CNA should not be taking residents out to smoke and leaving no staff on the hallway. The facility’s policy on answering call lights stated that the purpose of the procedure was to respond to residents’ requests and needs, but the observed and reported delays demonstrated a failure to follow this policy.
Penalty
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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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