Failure to Protect Cognitively Impaired Residents From Non-Consensual Physical Contact
Summary
The deficiency involves the facility’s failure to ensure that residents with severe cognitive impairment were treated with dignity and respect and protected from unwanted physical contact. Facility policy on Resident Rights, revised 1/2024, states that residents have the right to a dignified existence and to be treated with respect and dignity. Resident #1, admitted in October 2025 with diagnoses including psychotic disorder and Alzheimer’s disease, had a Quarterly MDS dated 1/23/26 indicating severely impaired cognitive patterns, and his/her health care proxy was activated on 1/19/26. Resident #2, admitted in December 2022 with unspecified dementia and psychotic disturbance, had an Annual MDS dated 11/14/25 showing severely impaired cognition and a court-appointed guardian as of 1/31/23. Resident #3, admitted in April 2025 with cerebral infarction and adjustment disorder with anxiety, had a Quarterly MDS dated 10/10/25 indicating severely impaired cognition and a court-appointed guardian as of 7/29/25. According to the Health Care Facility Reporting System, the facility reported multiple incidents in which Resident #1 initiated physical contact with Residents #2 and #3 without their consent. On 1/09/26, Resident #1 kissed Resident #3 and hugged Resident #2 without their consent. On 1/16/26, Resident #1 massaged Resident #3’s shoulders without consent. On 2/01/26, Resident #1 touched or groped Resident #2’s breast and groin area over clothing without consent. Social Workers #1 and #2 reported that they met with Resident #1 on 1/12/26 and 1/16/26 to discuss personal boundaries among residents; although Resident #1 verbalized understanding during these conversations, he/she appeared to forget the discussions and their content almost immediately afterward. During a telephone interview on 2/17/26, the Director of Nursing stated that Resident #2 was visibly upset and shaken following the incident in which Resident #1 touched his/her breast and groin area over clothing. These events demonstrate that the facility did not effectively prevent repeated, non-consensual physical contact between residents with severe cognitive impairment, resulting in a failure to uphold residents’ rights to dignity and respectful treatment.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Resident rights were violated when the NHA and a maintenance employee searched a resident’s room and took his camera without his consent while he was away at an outing. The resident, who had pain and difficulty walking, said his belongings were searched without permission, and his roommate confirmed the event. The NHA later acknowledged the resident-rights concern.
Missing Personal Items Not Returned or Replaced: Two residents reported missing clothing and other personal belongings that staff had not resolved, and grievance records showed multiple complaints about missing items. Observation of the laundry area found unlabeled clothing, shoes, and blankets stored in carts and on shelves, while staff said items often accumulated without names, were not routinely delivered to residents, and were sometimes donated or redistributed.
Oxygen Concentrator Not Inventoried in Resident Property Record: A resident with CHF, OSA, and atrial fibrillation had an oxygen concentrator from home at the bedside, but it was not listed in the resident's clothing and possessions inventory. The resident said he used the concentrator himself when needed and that his belongings record had not been updated after returning from the hospital. The LVN and DON confirmed there was no documentation of the concentrator in the inventory or nursing notes.
A resident’s urinary catheter was repeatedly observed hanging from the bedframe and visible from the doorway. The resident said it bothered him/her that the Foley could be seen, and an LPN noted the catheter was not covered. The charge nurse stated it was likely a hospital Foley that had remained in place since the resident returned and should have been changed out or at least covered.
Failure to Address Resident's Facial Hair and Dignity: A resident with Parkinson's disease, dementia, and ADL self-care deficits was observed on multiple occasions with long facial hair on her upper lip and chin. She stated she wanted it shaved, said staff had not offered, and reported it made her feel like a man. The DON and an MDS LVN stated grooming includes offering hair removal when residents want it, and a CNA confirmed the facial hair was present.
Failure to provide dignified dining assistance: A resident with stroke, diabetes, and dementia, who had a BIMS score of 3 and was dependent on staff for meals, was served lunch in the dining room but did not receive help eating until 20 minutes after the tray was delivered. The RNS confirmed the delay, and the DON confirmed the facility failed to provide a dignified dining experience.
Resident room searched and camera confiscated without consent
Penalty
Summary
The facility failed to obtain consent before searching a resident’s personal possessions and room, and it confiscated the resident’s camera without the resident being aware of the search. Facility policy stated that residents have the right to a dignified existence and to retain and use personal possessions to the maximum extent space and safety permit. The Nursing Home Administrator reported that, after being told the resident had a camera in his room, he and a maintenance employee went to the resident’s room and searched it while the resident was away on a resident outing. The resident’s clinical record showed diagnoses including pain and difficulty walking. The resident stated that his roommate told him the NHA and maintenance employee searched his room and took his camera without permission, and he said he keeps his belongings bagged in drawers and the closet so no one goes through them. The roommate confirmed the room search occurred, and the NHA later acknowledged understanding the resident-rights concern related to searching the room without notifying the resident first and taking the resident’s personal property.
Missing Personal Items Not Returned or Replaced
Penalty
Summary
The facility failed to ensure residents’ right to retain and use their personal possessions for two residents with missing belongings. One resident in room 127W reported that staff had been told on several occasions that clothing, tennis shoes, and a blanket were missing; the resident stated the items had been labeled with the resident’s name using a black marker, but they were neither returned nor replaced. Another resident in room 111P also reported missing personal items to several facility staff members and had not received any resolution regarding the missing belongings. A review of the grievance log showed six grievances filed between 12/11/2025 and 05/01/2026 related to missing personal items, and the grievances documented that the residents’ items were neither returned nor replaced. During observation of the laundry room, several collections of clothing, shoes, and blankets without names were seen in a laundry cart, on a table near the dryers, and on a shelf; Staff A verified the items did not have name labels and said staff were unsure which residents they belonged to. The Social Services Director stated most grievances were related to missing items, and the Laundry Assistant said resident clothing was not delivered because resident linens and towels were the priority and unnamed clothing continued to accumulate in the laundry room. The Nursing Home Administrator stated unnamed clothing was donated about once per month, sometimes given to residents with fewer belongings, and occasionally taken to the activities room for residents to identify missing items.
Oxygen Concentrator Not Inventoried in Resident Property Record
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity by not ensuring the resident's oxygen concentrator was inventoried in the Resident's Clothing and Possessions record. The resident was admitted with diagnoses including heart failure, obstructive sleep apnea, and atrial fibrillation. The H&P indicated the resident had capacity to make decisions, and the MDS indicated the resident could make himself understood and understand others. During observation, the resident was seen in his room with an oxygen concentrator turned off at the right side of the bed with nasal cannula tubing attached. The resident stated he brought the concentrator from home, had used it for a long time, and could apply the tubing and turn it on himself when needed. He also stated he had asked if it was okay to bring it in and said no one had updated his personal belongings after he returned from the hospital. Record review showed the resident's chart contained no order for oxygen therapy administration or monitoring, while the Weights and Vitals Summary documented oxygen via nasal cannula on several dates. The LVN stated there was no mention of the oxygen concentrator in the nursing notes or the Resident's Clothing and Possessions form, and the DON stated the inventory should be updated on the day of admission or after admission. The DON also stated the inventory protects residents' property rights and helps prevent misappropriation of property.
Visible Foley Catheter Not Covered
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect when a urinary catheter was observed hanging from the bedframe and visible from the doorway on multiple observations. During interviews, the resident stated it bothered him/her that the Foley could be seen from the door. An LPN observed that the Foley was visible and not covered, and stated the facility’s Foley catheters normally have a cover attached and are usually changed on admission. The charge nurse stated it had likely been that way for a while because it was a hospital Foley rather than the facility’s, and that the resident had been back since the prior weekend but the catheter should have been changed out or at least covered.
Failure to Address Resident's Facial Hair and Personal Grooming Preference
Penalty
Summary
The facility failed to ensure Resident #51 was treated with respect and dignity by not ensuring her facial hair was addressed according to her preference. Resident #51 was admitted with diagnoses including Parkinson's disease, muscle weakness, lack of coordination, dementia, and anxiety. Her quarterly MDS documented that she was usually able to make herself understood, usually understood others, and had a BIMS score of 9/15, indicating moderate cognitive impairment. Her care plan identified an ADL self-care performance deficit related to dementia and Parkinson's disease and stated she required extensive assistance with personal hygiene care. Observations on 6/23/2026, 6/24/2026, and 6/25/2026 showed long facial hairs on her upper lip and chin. During interview, Resident #51 stated she wanted her upper lip and chin shaved, was not aware she had facial hair, and said staff had not offered to shave her. She stated the facial hair made her feel like a man and that she did not want facial hair. The DON stated facial hair should be offered to be shaved for both men and women by CNAs and that staff were to provide care and ensure it was in the care plan. A CNA confirmed the resident had long hairs on her upper lip and chin, and an MDS LVN stated grooming included hair removal if residents wanted it.
Failure to Provide Dignified Dining Assistance
Penalty
Summary
The facility failed to provide a dignified dining experience for one resident during lunch meal service in the main dining room. Resident R3 was admitted with diagnoses including stroke with left side weakness, diabetes, and dementia. The resident’s MDS indicated a BIMS score of 3, and Section GG showed the resident was dependent on staff for meals. The care plan also indicated the resident needed assistance with eating. During observation, 16 residents were seated for lunch and the first tray was served at 11:35 a.m. Resident R3’s tray was served at 11:45 a.m. At 11:55 a.m., the resident stated, “Can you help me?” Staff did not assist the resident to eat until 12:05 p.m., 20 minutes after the meal tray was delivered. The RNS confirmed the tray delivery time and the delay in assistance, and the DON later confirmed the facility failed to provide a dignified dining experience for Resident R3.
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