F0550

E

Failure to Provide Dignified, Responsive Care and Respect Resident Rights

Canonsburg, Pennsylvania Survey Completed on 04-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide care in an atmosphere of dignity and respect and to protect residents’ rights to be free from neglect, interference, and dismissal of their needs. A facility document outlining resident rights states that residents must be treated with dignity and respect, be able to make their own schedules, and be free from abuse and neglect. A letter signed by nine residents reported that aides and other employees were frequently on their cell phones or wearing earbuds, talking, eating, watching videos, or listening to music instead of working. The letter described residents being left in the dining room until late in the evening while aides sat in breakrooms on their phones, residents not being fed, being left in dirty briefs for hours, waiting hours to be transferred from wheelchairs to beds, staff carrying hot plates in one hand and cell phones in the other while residents waited, and aides vaping in hallways and in the employee bathroom.

During a resident group interview, 13 of 14 residents reported that staff ignored their care needs, turned off call lights without providing care, and that when concerns were brought to administration, they were told “We will look into it,” but residents stated this did not occur. Residents reported staff using phones while providing care, widespread delays in assistance getting in and out of bed, and feeling dismissed, dehumanized, and fearful of retaliation if they filed complaints. Individual residents described specific incidents: one resident reported waiting until late at night to be put to bed after being placed in a chair in the morning, despite ringing for help for a long time, and feeling completely ignored and “like a table.” Another resident reported being left on a bedpan through dinner after staff refused to assist, and another stated they were left sitting in urine and feces for about eight hours, developing a rash and being inadequately cleaned, with cream applied repeatedly without proper washing.

Additional interviews reinforced these concerns. One resident reported having to call a family member to get staff to respond after being left in a room with the door shut, waiting an hour to an hour and a half for assistance. Another resident stated that staff would answer the call light, say they would return, and then never come back. A resident reported that during a meeting with the Administrator, the focus was on profit rather than patient care. Several residents described feeling that staff did not care about them, being rushed during care, being cleaned with a pillowcase due to lack of washcloths, and being left in soiled briefs long enough to cause skin irritation. One resident, who stated she was not incontinent, reported repeatedly waiting a long time for help to use the bedpan, not always receiving fresh water, and seeing staff walk by without entering her room, leading her to feel ignored and unworthy. The Nursing Home Administrator confirmed that the facility failed to provide services in an atmosphere of dignity and respect for multiple residents identified in the survey.

Plan Of Correction

Resident R9 is no longer in the facility. The social worker interviewed R21, R26, R63, R64, and R86. Any voiced concerns will be investigated without fear of retaliation. The social worker will document the follow-up of these investigations in the appropriate location

The administrator requested that she attend the resident council meeting regularly.

Will review with each current resident their preferred time to get out of bed and return to bed. This will be documented in the nurse aide documentation system and care planned.

The social worker and the administrator will interview the current resident population to address any areas of concern or complaints.

Resident interviews/satisfaction surveys/follow-up resident council interview will be completed to ascertain if the changes made have improved the life of the residents related to care. We will interview

Five residents a week for four weeks and then monthly ongoing

The staff have been educated on timely completion of ADL and incontinent care per care plan, The facility staff will be educated on the cell phone/earbud policy: they are not permitted in resident care areas. And that No Vaping is allowed in the facility. Signs indicating No Vaping have been posted at the front and back entrances. Facility Staff will be educated on the Call light policy and their requirement to assist answering call lights to their level of ability. Sensitivity training will be completed with the Nursing staff. Agency staff will also be required to view this training. Audits for the Cellphone/Earbud policy, Vaping, and call light response times will be completed by the DON/Designee four times weekly two audits per shift and monthly times three, with two audits per shift. occurring on varying units and times of the day.