F0550

E

Failure to Maintain Resident Dignity in Clothing, Catheter Privacy, and Dining Access

Easton, Maryland Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

Facility staff failed to maintain resident dignity in multiple ways, beginning with inadequate clothing and linen management for one resident. On one observation, this resident was found lying in bed with no clothes on, covered only by a blanket that had a dried yellow stain, with a fitted sheet stained with dried food and yellow discoloration, and half of a diaper on the fall mat next to the bed. A hospital gown was observed on the floor near the bathroom alcove. Later, the same resident was observed in the dining/activity room crying, stating that they were cold and that women were supposed to wear long pants, while wearing only a short-sleeved shirt, khaki shorts, and slipper socks. A GNA reported that the resident had no other clothes in the room. In the laundry room, a large backlog of personal laundry was observed, and laundry staff reported that personal laundry had not been done over the weekend, that only one of three commercial dryers and a small non-commercial dryer were functioning, and that it was taking 4–5 days to complete laundry. The Director of Maintenance and Housekeeping confirmed that two dryers and one washer were not working and that staff were unable to keep up with personal laundry.

Additional dignity concerns were identified for residents with Foley catheters. One resident was observed lying in bed wearing a hospital gown with a Foley catheter drainage bag hanging on the side of the bed, visible and not placed in a privacy/dignity bag. Another resident was observed lying in bed with a Foley catheter drainage bag visible from the hallway, also not covered by a dignity bag. The DON confirmed that residents with Foley catheters should have dignity bags and provided the facility’s Catheter Care Policy, which states that privacy bags will be available and catheter drainage bags will be covered at all times while in use. These observations showed that the facility did not follow its own policy regarding the use of privacy/dignity bags for catheter drainage bags.

Residents also reported restrictions on their ability to dine in the dining room for dinner and on weekends, affecting their right to dignity, self-determination, and socialization. Multiple residents stated that they would like to use the dining room for dinner and to socialize with other residents, but that staff would not allow it, reportedly due to insufficient staffing. Observation of dinner service showed that residents on two units received dinner trays in their rooms, and the dining room was dark and empty during the dinner hour. Resident council notes documented prior concerns from residents about not being able to eat dinner and weekend meals in the dining room, and a council concern form showed that the Administrator had responded that the dining room was only open for breakfast and lunch on weekdays because there was not enough staff to support dinner or weekend meals. The Dietary Manager and Activities Director both stated they understood that dinner and weekend dining room service were not provided due to staffing limitations, and the Administrator confirmed that residents could not use the dining room for dinner and weekends because of lack of staff.