Resident Left Overnight on Hallway-Visible Couch in Soaked Brief, Violating Dignity and Privacy
Summary
The deficiency involves the facility’s failure to ensure a resident’s dignity, privacy, and basic care needs were maintained during an overnight shift. The resident was an elderly female with severe cognitive impairment (BIMS score of 5), dementia with behavioral disturbance, cognitive communication deficit, muscle weakness, difficulty walking, insomnia, unsteadiness, and urinary frequency. Her care plan and MDS documented that she used a wheelchair, was dependent for toileting and transfers, required substantial/maximal assistance, and was to receive toileting assistance every two hours and as needed, with incontinent care after each episode. She was also on hospice with interventions to keep her clean and comfortable, and to maintain her dignity by being kept clean and dry. Active orders included brief checks every three hours and assistance of one to two staff for bed mobility and transfers. On the night in question, an LVN assigned to another hall (LVN C) was called to assist an agency LVN (LVN D) working her first shift in the facility on the 400 hall. When LVN C entered the suite shared by the resident and another resident, she observed the resident asleep on a couch in the entryway, visible from the hallway, wearing only a t‑shirt and a soaked brief. LVN C told LVN D that the situation was not acceptable, but LVN D responded that the resident would sleep wherever she wanted and stated she did not have time to “baby talk” residents. LVN C then returned to her own hall and called the on‑call ADON to report concerns about the residents on the 400 hall, including this resident lying on the couch in a soaked brief and t‑shirt. Camera footage later reviewed by the administrator showed that LVN D did not enter any resident room on that hall until after 10:00 PM and, throughout the night, did not remain in any room for more than two minutes, except for a three‑minute period around 4:30 AM when she and LVN C entered the suite of this resident and another resident. When day shift staff arrived the following morning, RN F and LVN H, after being alerted by LVN C, found the resident still asleep on the couch in the entryway to her suite, in view of the hallway, wearing only a t‑shirt, with a soaked brief on the floor next to the couch and urine soaking the couch around her. LVN H noted the resident’s wheelchair was next to her and that the resident’s bed was unmade. The resident later did not recall sleeping on the sofa. Multiple staff members, including LVNs, CNAs, the social worker, dietary staff, ADONs, the DON, and the administrator, stated in interviews that leaving a resident in a wet or soiled brief, or sleeping overnight on a couch in view of the hallway in only a t‑shirt and brief or just a t‑shirt, was not acceptable, was considered neglect, and negatively affected dignity, privacy, and basic care expectations. Facility documents, including the admission packet and the Patient/Resident Rights policy, stated that residents have the right to a dignified existence, privacy, and to be treated with respect and dignity, and that the facility must protect and promote these rights and provide care in a manner that maintains or enhances quality of life. The resident’s care plan and orders required regular toileting assistance, incontinent care after each episode, monitoring of appearance, and measures to keep her clean, dry, and comfortable, including checks of her brief every three hours. Despite these documented needs and interventions, the resident was left overnight on a couch in a public‑view area, inadequately clothed and in a soaked brief that was ultimately removed and left on the floor, with urine saturating the couch. The agency LVN assigned to her hall reported being alone without CNA support and unable to perform transfers due to a back injury, and stated that the resident had refused care and insisted the couch was her bed. However, the video evidence and staff interviews showed that the LVN provided minimal in‑room care throughout the night and did not ensure the resident was toileted, cleaned, appropriately dressed, or placed in bed or otherwise covered in a private setting. This sequence of inactions and observations led to the determination that the facility failed to treat the resident with respect and dignity and to provide care in an environment that maintained or enhanced her quality of life, as required by resident rights and facility policy. Staff interviews consistently characterized leaving a resident in unchanged, wet briefs and exposed in a public‑view area as neglectful and as a violation of dignity and privacy. The DON, ADONs, and other staff stated that any staff member who observed such a situation was responsible for intervening, including waking the resident, returning her to bed, dressing and covering her, or at minimum providing a blanket and pillow and ensuring she was not visible from the hallway. The facility’s own resident rights documents emphasized the right to safe, decent, and clean conditions, courtesy, consideration, respect, and privacy in personal care and accommodations. The events of that night, as documented by staff accounts, video footage, and the resident’s condition when found by day shift, demonstrated that these standards were not upheld for this resident.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with hemiplegia, hemiparesis, and vascular dementia was transferred in a mechanical lift from her room into a hallway to a reclining shower bed while only partially covered with a bath sheet, leaving her hips and buttocks exposed to others in the area. The resident said she did not like being left exposed, and staff stated the bed was usually placed outside her room because of space limits, though the DON expected her dignity to be preserved during the transfer.
A facility failed to provide a dignified dining experience for two residents who needed feeding assistance. One resident was left waiting while another resident at the same table was assisted and a third fed himself, and another resident received a tray but was not helped until staff finished assisting someone else at a different table. A nurse aide stated there were only two staff in the room and four residents who needed feeds.
Cell Phone Use During Resident Care: CNAs were observed by 11 confidential residents using personal cell phones while providing showers, peri-care, and other hands-on care, as well as while walking in halls, at the nurses’ station, and in the dining area. Residents said the phone use made them feel ignored, embarrassed, and that their privacy was violated. The DON and ADM stated staff should give residents full attention and not use cell phones in patient care areas, and the facility policy required residents be treated with kindness, respect, dignity, and confidentiality.
A PTA entered two residents’ shared room without knocking or announcing herself first. One resident had arthrogryposis multiplex congenita, tracheostomy dependence, and respirator dependence, and both residents had severely impaired cognitive skills and were dependent on staff for multiple ADLs. The PTA stated she should have knocked and introduced herself, and the DON said staff should knock and announce themselves before entering to respect residents’ dignity and rights.
A resident with quadriplegia and spinal stenosis missed a standing off-campus PT appointment after transport was not properly coordinated. A CNA escorted him to the pickup area, where Driver 1 said no driver was available and sent him back to his room, while Driver 2 later documented the trip as canceled without notifying the unit that she was available. RN staff did not verify transportation, and the resident became upset and reported feeling neglected and that his care was less important than other residents’ care.
A resident with moderate cognitive impairment, MS, neurogenic bladder, an indwelling catheter, and a left nephrostomy tube had his nephrostomy drainage bag left uncovered and visible from the hallway while seated in a Broda chair with his room door open. The care plan directed staff to ensure he was appropriately covered and dignity was provided, and the RNCM and DON confirmed the uncovered bag was a dignity concern.
Failure to Preserve Resident Dignity During Shower Transfer
Penalty
Summary
The facility failed to maintain Resident #67’s dignity during a shower transfer when two nurse aides moved her in a mechanical lift from her room into the common area hallway to a reclining shower bed on the other side of the hall. Resident #67 had diagnoses including hemiplegia, hemiparesis following cerebral infarction affecting the right dominant side, and vascular dementia. Her quarterly MDS indicated she was severely cognitively impaired, required a wheelchair for mobility, was dependent on staff for transfers, dressing, and bathing, and had a care plan that included assistance with positioning, transfers, toileting, personal hygiene, and bathing as needed. During continuous observation, NA #1 and NA #2 transferred Resident #67 with a bath sheet covering the front of her nude body, but her bare hips and the bare sides of her buttocks were exposed while she was moved through the hallway. Other staff members and residents were present in the hallway during the transfer. Resident #67 later stated that the nurse aides would cover the front part of her body with a sheet and leave her sides exposed, and that she really did not like that. Her care plan also addressed behavioral symptoms, including undressing with the door open, refusing care, crying, and cursing, and included providing an appropriate level of privacy. The nurse aides stated they usually placed the reclining shower bed right outside Resident #67’s room because there was not enough room to place both the mechanical lift and the bed inside the room. NA #1 said the bed had been moved across the hall on the observed occasion and that they typically would not push the lift across the hall. NA #2 stated her normal process was to undress Resident #67 in bed and cover her with a shower sheet before transfer, and she did not realize Resident #67 was exposed. The DON later observed that the mechanical lift fit between the beds in the room, but the reclining shower bed barely fit at the foot of the bed and could not safely be used inside the room due to space constraints. The DON and Administrator stated they expected staff to preserve Resident #67’s dignity and ask about her shower preference.
Failure to Provide Dignified Dining Assistance
Penalty
Summary
The facility failed to provide a dignified dining experience for two residents, R16 and R118. The facility policy on feeding indicated that residents are to be fed in a therapeutic and dignified manner. During an observation in the dining room, R16 was seated at a table with two other residents, one of whom was being assisted with a meal by a nurse aide while the other fed himself, but R16 was not fed until the other resident was finished at about 12:05 p.m. During the same observation, R118 had received his tray while staff continued passing trays in the dining room, and he was seated with another resident who fed himself, but R118 was not assisted with his meal until 12:05 p.m., after a registered nurse finished assisting another resident at a different table. A nurse aide stated that there were only two staff in the room and four residents who needed feeding.
Cell Phone Use During Resident Care
Penalty
Summary
The facility failed to treat residents with respect, dignity, and care in a manner that promotes quality of life for 11 of 11 confidential residents when CNAs used personal cell phones while providing care. Residents stated that CNAs were on their phones during showers, peri-care, care in resident rooms, while walking in hallways, at the nurses’ station, and in the dining area during meals, including talking and texting through earpieces while care was being provided. The residents said this made them feel ignored, not a priority, embarrassed, and concerned that the CNA could make a mistake because of distraction, and they stated their privacy was violated. During interviews, the DON and ADM stated residents should receive privacy, full attention, and dignity during care, and that cell phones should not be used in patient care areas but only in the break room or during breaks. They also stated staff were trained on resident rights, dignity, privacy, and cell phone use during orientation and ongoing education, and that rounding was used to monitor compliance. The facility policy titled Resident Rights stated employees shall treat residents with kindness, respect, and dignity and protect privacy and confidentiality.
Failure to Knock Before Entering Residents’ Room
Penalty
Summary
The facility failed to provide care in a manner that promoted and maintained residents’ rights for two sampled residents when Physical Therapy Assistant 1 entered their shared room without knocking or announcing herself first. During an observation on 6/30/2026 at 3:45 p.m., PTA 1 was seen entering the room without knocking or introducing herself. In an interview immediately afterward, PTA 1 stated she did not knock or introduce herself before entering and said she entered to see whether Resident 2 was in the room. She also stated she should have knocked and introduced herself out of respect for the residents and to uphold their rights. Resident 2’s admission record showed diagnoses including arthrogryposis multiplex congenita, tracheostomy dependence, and respirator dependence, and the MDS dated 6/1/2026 indicated severely impaired cognitive skills for daily decision making and dependence on staff for oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, and mobility. Resident 3’s admission record showed a diagnosis of shaken infant syndrome, and the MDS indicated severely impaired cognitive skills for daily decision making and dependence on staff for oral hygiene, toileting hygiene, bathing, dressing, personal hygiene, and mobility. The DON stated that all staff should knock and announce themselves before entering residents’ rooms, and the facility policy stated residents are to be treated with consideration, respect, and full recognition of dignity and individuality, including privacy in treatment and in care of personal needs.
Missed Off-Campus Appointment Due to Poor Transportation Coordination
Penalty
Summary
The facility failed to accommodate a resident’s right to access services outside the facility when transportation for an off-campus medical appointment was not properly coordinated. The resident was admitted with diagnoses including quadriplegia, acromegaly and pituitary gigantism, and spinal stenosis. He had a standing appointment twice a week at an off-campus specialty clinic for physical therapy related to spinal injuries, and he had a scheduled pickup time of 10 a.m. for an 11 a.m. appointment. On the day of the appointment, a CNA escorted the resident to the pickup location, where Driver 1 told them he was the only driver and could not take the resident because he was assigned to residents going to appointments within the local campus. The resident was then escorted back to his room. The resident stated he was not told that another driver was available and later learned that Driver 2 had been available if he had remained downstairs. Driver 2 documented the appointment as canceled, stated she did not call the unit to notify staff she was available, and did not confirm with anyone that the appointment had been canceled. RN 1 stated the resident and CNA 1 told her there was no driver available, but she did not check for a driver or help coordinate transportation. Driver 1 stated he did not tell them another driver was coming because he did not know when the other driver would arrive. The resident’s care plan identified a risk for emotional distress related to lack of transportation to physical therapy appointments and included nursing coordination with transportation staff. Social work notes documented that the resident appeared unhappy and resigned after being told there was no driver, and he reported feeling neglected and that other residents’ care was more important than his.
Uncovered nephrostomy bag visible from hallway
Penalty
Summary
The facility failed to maintain a resident's dignity when R5's nephrostomy drainage bag was left uncovered and visible from the hallway. R5's quarterly MDS identified moderate cognitive impairment, need for assistance with ADLs, multiple sclerosis, neurogenic bladder, and an indwelling catheter. The care plan dated 6/1/26 identified R5 as incontinent of bowel and bladder related to multiple sclerosis and decreased mobility, and noted a left nephrostomy tube due to kidney stones and a Foley catheter. The care plan directed staff to provide incontinence care, monitor for signs and symptoms of a UTI, empty the left nephrostomy as ordered, and ensure R5 was appropriately covered and dignity was provided. During an observation on 7/1/26 at 12:42 p.m., R5 was seated in a Broda wheelchair in his room with the door open to the hallway, and the nephrostomy drainage bag was hanging uncovered from the left armrest of the chair and visible from the hallway. During a later observation and interview, a TMA stated the bag was usually hung on the armrest of R5's wheelchair. The RNCM and DON later confirmed the nephrostomy drainage bag was not covered and was visible from the hallway, and stated it should have been covered because the uncovered bag was a dignity concern.
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