F0550

E

Failure to Ensure Dignity, Respect, and Adequate Incontinence Care for Multiple Residents

Lebanon, Missouri Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves multiple failures to honor residents’ rights to dignity, respect, self-determination, and appropriate care, particularly related to staff interactions, incontinence care, and response to call lights. Resident #4, who is cognitively intact with significant mobility limitations, pain, osteoporosis with pathological fracture, and urinary incontinence, reported that a nurse aide (NA B) repeatedly failed to return after agreeing to assist and ignored requests for help, including assistance to prepare for scheduled smoking breaks. Resident #4 described NA B yelling down the hall, accusing the resident of “putting things in my mouth,” and characterized NA B as rude, lacking compassion, and potentially aggressive. The resident also reported that another CNA told the resident to be quiet when calling for help, that staff often told the resident to wait and then did not return, and that the only way to get staff attention was to yell. Progress notes documented that the resident frequently yelled and screamed for help if not assisted right away, and Resident Council minutes noted call lights not being responded to on time.

Resident #4 further reported significant issues with incontinence care and supplies. The resident stated that staff did not check on or change incontinence briefs for extended periods, leading to a brief that, when weighed with a CNA, was found to weigh about one to 1.3 pounds, and that this was reported to LPNs and the DON, who allegedly responded dismissively. The resident reported being left without appropriate briefs, being out of briefs the prior day, and that staff used briefs that were too big or too small because the facility frequently ran out of the correct size. CNAs corroborated that the facility had ongoing supply shortages of briefs and wipes, that several residents did not have enough briefs, that staff sometimes had to use bariatric or incorrect sizes, and that wipes were unavailable at times, requiring use of wet paper towels and washcloths. One LPN stated that residents may be left soiled at night because some mornings residents were found soaking wet. The DON acknowledged a shortage of briefs, ordering constraints tied to budget, and that staff were instructed to place only a few briefs in rooms at a time.

Resident #5, cognitively intact with osteoporosis, anxiety, depression, COPD, and frequent incontinence, reported that NA B was rude and talked over the resident about the aide’s personal dating life while the resident was being changed, making the resident uncomfortable and leading the resident to request that NA B no longer provide care. LPN J confirmed that Resident #5 complained about NA B’s rudeness and that NA B and another CNA had an inappropriate conversation about dating while providing incontinence care. LPN J also reported that residents had complained about NA B being rude, and had personally heard NA B say impatiently in front of the nurse’s desk, “My God, [resident’s name], what do you want now?” Other staff, including a CMT and CNA, stated that staff were expected not to yell at residents, not to talk about personal lives, and not to talk over residents during personal care, indicating that NA B’s conduct was inconsistent with these expectations.

Resident #6, cognitively intact with paraplegia, depression, and chronic pain, reported that when the resident asked NA B to remake an improperly made bed, NA B became irritated, walked off to use a phone, did not return to complete the task, and subsequently ignored the resident when passing by. Additionally, CNA D reported witnessing NA B inappropriately restrain another resident (Resident #2) by holding the resident’s arms and hands behind the back “like he/she was being arrested” while walking the resident from the business office manager’s office to the special care unit, during which the resident was upset, crying, and verbally refusing. CNA D stated that other staff witnessed this incident and that it was reported to the DON. Across these events, the administrator and DON both articulated expectations that staff should not tell residents to be quiet, should not yell at or talk over residents, should not ignore residents, and should respect residents’ wishes, but the described staff behaviors and supply failures did not align with those expectations and contributed to the identified deficiency in resident rights and dignity.

Additional documentation supports a pattern of delayed response to residents’ needs and disregard for resident comfort and preferences. Progress notes for Resident #4 described frequent yelling for help when assistance was not provided promptly, and staff interviews indicated that some staff told the resident that they were not the only resident needing care and that the resident should not yell because it disturbed others. The DON stated that if a call light was not answered as quickly as the resident wanted, the resident should not be yelling, and that staff encouraged call light use, while Resident Council minutes documented concerns about call lights not being answered timely. For Resident #5, progress notes described the resident as demanding and yelling out “help” after a few minutes when slightly incontinent, and preferring to stay in the room with the door closed, but there was no indication that staff adjusted their approach to address the resident’s expressed discomfort with staff conversations during care. Collectively, the report details multiple instances where staff actions and inactions, including rude and dismissive communication, failure to respond promptly to requests and call lights, inadequate incontinence care, and inappropriate physical handling, failed to uphold residents’ rights to dignity, respect, and appropriate care as outlined in facility policy and resident care plans.