Failure to Ensure Timely and Effective Call Light Response for Multiple Residents
Summary
The deficiency involves the facility’s failure to honor residents’ rights to timely response to call lights and basic care needs for multiple residents. One resident with heart failure, atrial fibrillation, COPD, and dependence on supplemental O2 experienced an oxygen concentrator malfunction and was placed on an oxygen tank that subsequently ran out. The resident developed a headache, dizziness, and lightheadedness, activated the call light, and waited approximately 25 minutes before staff responded. When staff did respond, they left the room to locate a full oxygen tank, placing the resident at serious risk of harm and demonstrating a failure to ensure basic medical safety and timely response. Another resident with a history of femur fracture, muscle disorders, falls, and moderately impaired cognition (BIMS 9/15) was dependent on staff for toileting and lower body dressing. Confidential persons reported that this resident needed to use the bathroom, was not attended to, and was later found on the floor of another resident’s room with pants down below the knees. A confidential person also reported activating the call light during a visit and waiting more than 30 minutes with no staff response, ultimately taking the resident to the bathroom themselves. They reported that staff became upset and stated visitors should wait for staff, but the resident could not hold it that long, would try to get up alone, and had multiple incontinence episodes while waiting for staff. The confidential person also reported finding the resident incontinent of bowel and changing the resident themselves due to long response times. A resident with stroke, diabetes, depression, and hemiplegia/hemiparesis, cognitively intact (BIMS 14/15) and dependent on staff for hygiene, toileting, bathing, dressing, mobility, and transfers, reported having a call light on for about 30 minutes with no staff entering the room. Observation showed the wall call light illuminated for the roommate, who denied activating it, while the resident’s own call light did not activate when pressed multiple times. Maintenance later adjusted the wall connection before the call light functioned. This resident reported that call light wait times could exceed 30 minutes and sometimes take up to an hour when calling for assistance after incontinence and for ice water. Another cognitively intact resident (BIMS 15/15) with peripheral vascular disease, depression, diabetes, and a left above-knee amputation, dependent on staff for toileting, bathing, lower body dressing, and transfers, was observed with the call light on and reported needing to be changed and wanting a drink. The resident stated that sometimes the call light worked and sometimes it did not, and that staff would turn off the light, say they would return, and then not come back, sometimes resulting in waits longer than 30 minutes. Surveyors observed the call light above this resident’s door visible from the nurse’s station, with staff present in and around the area and using a nearby breakroom, while the call light remained unanswered. Housekeeping entered a nearby room first, and later a staff member entered the resident’s room, turned off the light, then went into the breakroom. The resident subsequently received a drink but had not been changed. A further cognitively intact resident (BIMS 15/15) with anxiety disorder, heart failure, need for assistance with personal care, respiratory failure, and dependence on supplemental O2, dependent on staff for toileting, lower body dressing, mobility, and transfers, was observed with the call light on and reported that while it had not been on long at that moment, call light response times could be as long as an hour. Resident council minutes over several months documented repeated concerns that nursing call light response times were longer than normal or taking longer, with ongoing reports that call lights were not being answered timely. The ADON stated that call lights should be answered as soon as possible, within about 5 to 10 minutes, and that if a need was not met, the call light should remain on. Facility policy stated that call lights would be placed within residents’ reach and answered in a timely manner, and that staff should identify the location and answer promptly, turning off the light only if able to meet the resident’s request. Despite this, surveyor observations, resident interviews, and council notes showed ongoing delays, nonfunctioning or improperly connected call lights, and staff turning off call lights without meeting residents’ needs.
Penalty
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Staff failed to honor a resident’s expressed preference to use a mounted doorbell instead of knocking before entering the room. The resident had PTSD and a history of trauma, and knocking was a known trigger. During observation, a CNA knocked, rang the doorbell, and opened the door while the resident was being interviewed, despite a posted sign requesting staff ring the bell and not knock. Interviews confirmed staff knew the resident’s preference and trigger.
Failure to maintain resident dignity and privacy during care: multiple residents reported CNAs used personal cell phones while assisting with showers, peri-care, and other care, including texting and talking in resident areas and during meals. A resident with stroke-related paralysis and severely impaired cognition was observed receiving wound care with the door open and the privacy curtain not pulled, allowing others to see into the room while the LPN provided care.
A resident who was dependent on staff for toileting and transfers, and who was frequently incontinent, was left in bed in only a sweatshirt and brief while crying after staff told her to stay in bed and pee her pants so they could clean her up later. The resident said this happened often and that her call light was frequently turned off. Staff interviews confirmed she should not have been told to remain incontinent, and the DON stated residents should never be told to be incontinent because it is a dignity issue.
A resident with a foley catheter was observed with the catheter bag hanging uncovered on the side of the bed while the room door was open. The resident had diagnoses including stroke-related hemiplegia/hemiparesis and UTI, and the care plan noted a foley catheter related to neurogenic bladder. CNA staff stated the bag should have been covered, and the DON acknowledged it was a privacy issue.
Failure to Maintain Female Residents' Dignity With Unwanted Chin Hair: Three female residents were observed with visible chin hair after showers, despite needing staff assistance with bathing and grooming. Two residents had severe cognitive impairment and one had moderate cognitive impairment; one resident said the hair bothered her and another said she was waiting for the beauty shop to shave it off. Family members stated the residents would not choose to have beards and that the unwanted chin hair caused embarrassment and affected dignity.
A resident with impaired cognition, incontinence, and a catheter for neurogenic bladder had his catheter drainage bag visible in the commons area and later from the hallway, with clear yellow urine showing. Staff, including therapy, the IP, and an RN, did not arrange privacy, and the bag was also hung facing out toward the room entrance. The DON stated staff were expected to keep the blue side of the bag facing the public to cover it and maintain dignity.
Staff Failed to Honor Resident’s Doorbell Preference
Penalty
Summary
The facility failed to ensure staff treated Resident #39 with dignity and respect by honoring the resident’s expressed preference for how staff announced themselves before entering the room. Resident #39 was admitted with diagnoses that included PTSD and frontal lobe and executive function deficit, and stated during interview that knocking on the door was a known trigger related to a history of trauma. The resident preferred that staff use the mounted doorbell instead of knocking when the door was shut for privacy. During observation, CNA #2 approached the resident’s room, knocked on the door, rang the mounted doorbell, and then opened the door while surveyors were interviewing the resident. The resident responded, “Not now, I’m busy,” and the CNA closed the door. A sign posted outside the room stated, “Pls. Ring the Bell, Don’t Knock! STOP,” and a doorbell was mounted next to the sign. Interviews with the ADON and CNA #9 confirmed staff were aware of the resident’s preference and that knocking was a known trigger, yet the observed practice did not follow the resident’s stated wishes.
Failure to Maintain Resident Dignity and Privacy During Care
Penalty
Summary
The facility failed to treat residents with respect, dignity, and privacy by allowing staff to use personal cell phones while providing care and by failing to maintain privacy during wound care for one resident. Twelve confidential residents stated that CNAs used personal cell phones while assisting with showers, providing care in resident rooms, and performing peri-care, and that staff also texted and talked on phones while walking in hallways, at nurses’ stations, and in the dining area during meals. The residents stated this occurred on every shift and made them feel embarrassed, concerned about the quality of care, and that their privacy was violated. During interviews, the DON and ADM stated staff should not use cell phones or earbuds while providing care and should keep phones in breakroom lockers. They stated residents should receive undivided attention and that staff were trained on resident rights, dignity, privacy, and cell phone use during orientation, ongoing education, and in-services. They also stated staff were monitored through rounds, and both acknowledged that cell phone use in resident care areas could violate privacy and reduce attention to care. Resident #7 was a male resident with a history of cerebral infarction, left-sided hemiplegia and hemiparesis, and urinary tract infection, and his MDS indicated severely impaired cognitive skills for daily decision making. During observed wound care, LVN D did not close the door or pull the privacy curtain around the resident, and two female residents were seen passing by and looking into the room while care was being provided. LVN D stated she had been trained to close the door and pull the curtain but did not do so because she was waiting for the CNA, and the DON and ADM stated they expected the door to be closed and the curtain pulled for privacy during resident care.
Failure to Preserve Resident Dignity During Toileting Assistance
Penalty
Summary
The facility failed to ensure dignified care for one resident who was dependent on staff for toileting and transfers, frequently incontinent of bowel and bladder, and had diagnoses that included dementia, diabetes, non-traumatic spinal cord dysfunction, depression, heart failure, and asthma. Her care plan directed staff to assist her with toileting, provide incontinence care, and offer toileting every 3 hours so she could remain free of skin breakdown and have her dignity respected. She was also documented as being able to verbally ask for toileting assistance and requiring extensive assistance with transfers and toileting needs. During an observation, the resident was found lying in bed wearing only a sweatshirt and an incontinent brief, with no pants and not fully covered by bedding. She was crying and stated staff told her she had to stay in bed and could not get up, and that they told her to pee her pants and they would clean her up in bed. She stated this happened all the time and that nursing assistants shut off her call light just about every day. While she was crying, a nursing assistant entered, said she was wet and needed to be cleaned up, told her not to cry, and then provided incontinent care. During interviews, staff acknowledged the resident should not be told to go in her pants or be encouraged to remain incontinent. One NA stated the resident was encouraged to stay in bed because staff were short and the NA had other residents to care for, and that the resident had asked to get up but was waiting because she required assistance of 2. Other staff stated the resident should never be told to just go in her pants, that residents should not be told to be incontinent, and that such statements were a dignity issue. The DON stated staff were expected to provide care when requested and never tell a resident to be incontinent because it was a dignity issue.
Uncovered Foley Catheter Bag Observed With Door Open
Penalty
Summary
The facility failed to ensure a resident was treated with dignity when Resident #3’s foley catheter bag was observed hanging on the side of the bed without a cover while the room door was open. Resident #3 was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side and a UTI, and his care plan documented that he had a foley catheter related to neurogenic bladder. The facility’s Promoting/Maintaining Resident Dignity policy stated that residents are to be protected and promoted in their rights and treated with respect and dignity. During interview, CNA #1 stated the catheter bag should have been covered since the door was open, and the DON stated she had never thought the catheter should have been covered in the room with the door open and acknowledged it was a privacy issue.
Failure to Maintain Female Residents' Dignity With Unwanted Chin Hair
Penalty
Summary
The facility failed to treat three residents with dignity and respect when each had visible chin hair that was not consistently removed after bathing. Resident #1, a female resident with moderately impaired cognition, was dependent on staff for toileting and required assistance with bathing. Her record showed she was showered on 06/02/26, but on 06/03/26 and again on 06/04/26 she was observed with several white, approximately one-inch-long hairs on her chin. During interview, she stated the hairs bothered her and said she was waiting for the beauty shop ladies to come because they usually shaved her chin hair off for her. She also stated CNAs never shaved her chin. Resident #37, a female resident with severely impaired cognition, was dependent or required partial/moderate assistance across all ADLs except eating and required one staff member to assist with bathing. Her record showed she received a shower on 06/02/26. On 06/03/26, she was observed multiple times lying in bed with several dark and light grey hairs sprinkled across her chin, approximately half an inch long. During interview, her family member stated she would not choose to have a beard and that when at home she used a trimmer to remove unwanted chin hair. The family member also stated CNAs shaved her chin when they showered her. Resident #44, a female resident with severely impaired cognition, Parkinson's disease, lack of coordination, and muscle weakness, was dependent across all ADLs except eating and required two staff members for bathing. Her record showed she was showered on 06/02/26. On 06/03/26 and again on 06/04/26, she was observed with long, white, curling hairs on both sides of her chin. During interview, she stated it bothered her to have chin hair and that she did not like it. She said she could shave her chin if she had a razor and stated CNAs had shaved her chin in the past, but she did not know why they had not done so lately. Her family member stated the chin hair bothered her, that he had never seen her with chin hair before she came to the facility, and that she would become emotional and embarrassed if it was mentioned.
Visible Catheter Drainage Bag Not Kept Private
Penalty
Summary
The facility failed to ensure dignity was maintained for one resident who had moderately impaired cognition, was dependent on staff for dressing, bed mobility, and toileting, was always incontinent of bowel and bladder, and had intermittent catheterization for neurogenic bladder. The resident’s care plan identified a catheter and included an intervention to position the catheter bag and tubing below the level of the bladder and away from the entrance room door. During an observation, the resident’s urinary catheter drainage bag was visible while he was seated in his wheelchair in the commons area, with clear yellow urine showing and the bag hung under the wheelchair. After the resident was brought to his room, staff emptied the catheter drainage bag and hung it on the side of the bed facing out to the room entrance. On a later observation, the catheter drainage bag was uncovered in the commons area, with the clear side facing toward the hallway and elevator space so that clear yellow urine was visible from the hallway. Therapy staff, the infection preventionist, and the resident’s RN were present in the area and did not arrange privacy for the catheter drainage bag. Staff later stated the bag should be covered for privacy, and the DON stated staff were expected to keep the blue side facing the public to cover the bag and maintain dignity. The facility’s dignity policy stated catheter drainage bags and colostomy pouches should be covered with commercial covers or tucked out of plain sight.
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