Failure to Ensure Dignified and Respectful Care by CNAs
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were treated with dignity and respect, particularly in relation to care provided by two CNAs referred to as “the twins” or “the sisters.” One resident, R1, cognitively intact per a 12/2/25 assessment, reported that these staff were mean, had poor attitudes, and were physically rough when he did not comply with what they wanted. R1 stated the mistreatment escalated to the point that he needed to change rooms and that, prior to the move, he would rather remain soiled than have these CNAs provide care. After his room change, he reported that these CNAs no longer cared for him and that he preferred they not care for him at all. R1’s daughter confirmed that R1 had complained about the “evil twins” and requested that they have no contact with him, stating that they were unkind to the point that he refused care even when family was present. She reported this to the social services staff member (V11), who she said knew exactly which staff she meant, and she expressed concern that the CNAs were known for such behavior yet continued working there. Another CNA (V9) identified the twins as V3 and V4 and stated that residents had requested they not provide care, including one resident who would rather sit in urine than accept their assistance and who sought help from staff on other hallways. Assignment sheets showed V3 and V4 were regularly scheduled to work in zone 2 during the relevant period. A second resident, R2, admitted for antibiotics and therapy following a hip replacement complicated by sepsis, also had concerns related to the same CNAs. His wife reported in a grievance that staff, identified as “the twins,” did not take their time, moved him too quickly, and caused him discomfort when transferring and seating him, including jerking him out of bed, plopping him into a wheelchair, and allowing him to fall hard onto the toilet. She stated that these CNAs did not treat him with dignity, were rough and rude, and that he was afraid to speak up for fear of retaliation and wanted to go home early. The DON (V2) acknowledged being aware of concerns about V3 and V4 from both R1 and R2, describing the CNAs as task-oriented and noting that R1’s family had asked that they not be his caregivers, leading to his move to another zone. The administrator (V1) also acknowledged awareness of resident complaints and a grievance related to these caregivers.
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