F0550

D

Failure to Maintain Resident Dignity During Mealtime Assistance

Augusta, Kentucky Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in resident dignity when a certified nursing assistant (CNA) fed a resident from a standing position while the resident was seated at the dining room table. The facility’s Resident Rights Policy stated that residents have the right to be treated with respect and dignity and to receive services with reasonable accommodation for their needs and preferences. The facility’s Meal Supervision and Assistance policy instructed that residents should be positioned with the head and upper body as upright as possible and that staff should provide a relaxing, enjoyable environment during mealtime. During observation of a meal service, CNA1 was seen feeding the resident her entire meal while standing, rather than positioning herself at eye level.

The resident involved had late-onset Alzheimer’s disease, protein malnutrition, metabolic encephalopathy, and multiple co-morbidities, and was on a mechanically altered diet with thin liquids. Her most recent MDS showed a BIMS score of 1/15, indicating severe cognitive impairment, and documented swallowing concerns such as pocketing food and residual food after oral intake. She required supervision and intermittent hands-on assistance with meals, and her care plan required staff to assist with all meals and monitor for signs and symptoms of dysphagia. CNA1 later stated she usually sat beside the resident but stood on this occasion because another resident’s walker was in the way, and acknowledged she should have moved the walker and sat at eye level. The DON/IP and the Administrator both stated their expectation that staff assist residents with meals from an eye-level, seated position to support dignity and appropriate observation, confirming that the observed practice did not meet facility expectations.