F0550

D

Failure to Provide Clothing Protector During Meals Compromising Resident Dignity

Geneva, Illinois Survey Completed on 12-23-2025

Penalty

No penalty information released

Summary

Surveyors identified that staff failed to provide a clothing protector during meals to a resident with severe cognitive impairment, resulting in food spilling on her clothing. On the morning of 12/21/2025, the resident was observed in the dining room eating a pureed breakfast. She was severely cognitively impaired, fatigued, and had difficulty feeding herself, which led to multiple food residue spills on her shirt and pants. Despite this, she was not provided with a clothing protector. Later that day at lunchtime, the same resident was again observed in the dining room feeding herself pureed food with some unsteadiness using utensils, causing additional spillage on her shirt and pants, and again no clothing protector was provided.

A CNA who routinely cared for the resident stated that the resident was able to feed herself but required prompting and cueing, especially when fatigued, and that she required the use of a clothing protector to protect her clothing from food spillage. The CNA also stated that due to the resident’s cognitive impairment, she was dependent on staff to provide a clothing protector at meals. The DON reported that she expected staff to provide resident-centered care during meals, including rounding and providing clothing protectors to prevent spillage on residents’ clothing. The resident’s MDS documented severe cognitive impairment and a need for staff set-up and clean-up assistance with meals, and the care plan indicated she was at risk for complications due to cognitive impairment, was dependent on staff for care, and that staff were to anticipate her care needs. The facility’s Resident Rights policy stated that employees shall treat all residents with kindness, respect, and dignity.