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:
Failure to maintain resident dignity was identified when three residents with indwelling urinary catheters had drainage bags hanging on the bedframe without privacy covers, despite physician orders for privacy covers every shift. In addition, a resident who was ordered to be fed by staff was observed being fed by a nurse aide standing beside the bed during lunch, and the DON confirmed the dining experience was not dignified.
A resident with dementia, anxiety, and osteoarthritis was observed sitting naked on the bed in full view of the hallway while a CNA assisted with dressing. The care plan directed staff to assist with dressing, and the CNA stated the curtain had not been pulled after returning the resident from the bathroom. The ED confirmed the facility failed to maintain the resident's dignity.
Failure to provide a dignified dining experience: Four residents with significant diagnoses, including Parkinson’s disease, schizophrenia, cerebral palsy, TBI, and dysphagia, were brought to the assistive dining room for lunch but were not served their trays until more than 50 minutes after the posted mealtime. While other residents were already being assisted with eating, these residents were left watching the meal service, and the DON stated they should have been served at the same time as the others or not brought in until their trays were ready.
A facility failed to protect the dignity of two residents when an LPN administered insulin injections in the commons area in full view of surveyors, staff, and other residents. The LPN lifted each resident’s shirt, cleansed the injection site, and gave the subcutaneous insulin injection publicly rather than in a private area.
A resident with dementia, depression, and anxiety was seated in the dining room while other residents ate, but the lunch tray was not served with the group on two occasions. In a separate event, an LVN administered oral meds to another resident with intellectual disability and cerebral palsy in the dining room while wearing gloves, rather than in a private setting, which staff stated was not the facility’s practice and could be seen as disrespectful.
A resident with dementia and Alzheimer's disease had his beard completely shaved by two CNAs without his RP's consent. The RP stated the resident had worn his beard for many years and had not been seen without it, and the DON stated the RP should have been notified because the resident lacked capacity to make decisions for himself. The facility policy required staff to ask the resident or, when appropriate, the resident representative about grooming preferences upon admission.
Failure to Maintain Resident Dignity During Catheter Care and Dining
Penalty
Summary
The facility failed to maintain resident dignity by not ensuring privacy covers were applied to urinary catheter drainage bags for three residents. Resident R26, who had diagnoses of diabetes, high blood pressure, and coronary artery disease, had a physician order for catheter care to provide a privacy cover for the drainage bag every shift. During observation, the catheter drainage bag was hanging on the bedframe without a privacy cover. Resident R178, with diagnoses of diabetes, high blood pressure, and depression, also had an order for a privacy cover every shift, and the drainage bag was observed hanging on the bedframe without a privacy cover. Resident R179, diagnosed with COPD, atrial fibrillation, and heart failure, likewise had an order for a privacy cover every shift, and the drainage bag was observed hanging on the bedframe without a privacy cover. An RN confirmed that the bags should be covered and that the residents' dignity was not maintained. The facility also failed to provide a dignified dining experience for one resident who was ordered to be fed by staff. Resident R39, who had diagnoses of high blood pressure, heart failure, and diabetes, had a care plan and physician order for staff to feed all meals. During lunch observation on the 2B nursing unit, the resident was sitting upright in bed while a nurse aide stood beside the bed feeding the resident. The nurse aide stated that they should have been sitting down while feeding but did not know where the resident's chair was. The DON later confirmed that the facility failed to provide the right to a dignified dining experience for one of two lunches observed on 2B.
Failure to Maintain Resident Dignity During Dressing Assistance
Penalty
Summary
The facility failed to provide care and services to maintain a resident's dignity for one of 11 sampled residents. Resident R23 had diagnoses including dementia, anxiety, and osteoarthritis. The MDS dated [DATE] indicated the resident had mild cognitive impairment and required assistance with dressing. The care plan identified a self-care performance deficit related to dementia and directed staff to assist the resident with dressing. During observation on 8/4/2026 at 10:15 a.m., Resident R23 was sitting on the bed naked in full view of anyone walking by in the hallway while a CNA was assisting with dressing. During interview, the CNA stated that the curtain had not been pulled after bringing the resident back from the bathroom, and the Executive Director confirmed the findings and that the facility failed to provide care and services to maintain the resident's dignity.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect for 4 of 8 residents reviewed for respect and dignity. The facility’s Assistance with Meals policy stated that staff will serve resident trays and help residents who require assistance with eating, and that residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity. The facility’s Dignity policy stated that each resident shall be cared for in a manner that promotes and enhances well-being, satisfaction with life, and feelings of self-worth and self-esteem, and that residents are supported in exercising their rights during care. Resident #4 had diagnoses including Parkinson’s Disease and major depressive disorder. Resident #13 had diagnoses including schizophrenia and abnormal involuntary movement. Resident #19 had diagnoses including spastic quadriplegic cerebral palsy and anxiety disorder. Resident #44 had diagnoses including traumatic brain injury and dysphagia. During observation of the assistive dining room during the lunch meal, eight residents were present and only four were being assisted with eating after their meals had been delivered. Residents #4, #13, #19, and #44 were not served their lunch trays until after 12:10 PM, more than 50 minutes past the posted lunch mealtime, and were observed watching other residents who were already being assisted with their meals. The DON stated these residents should have been served at the same time as the other residents or not brought into the dining room until their trays were ready.
Failure to Protect Resident Dignity During Insulin Administration
Penalty
Summary
The facility failed to provide care for R4 and R1 in a manner that protected and promoted their dignity. On 08/04/2026 at 07:32 AM, observation in the commons area showed LN G pulling up R4's shirt on his left arm, cleansing the area with an alcohol wipe, and administering a subcutaneous insulin injection in his right upper arm while two surveyors, multiple facility employees, and numerous other residents could view the procedure from the four halls and dining room area. On 08/04/2026 at 07:40 AM, a similar observation in the commons area showed LN G pulling up R1's shirt on his left arm, cleansing with an alcohol wipe, and administering a subcutaneous insulin injection in his right upper arm in full view of two surveyors, multiple facility employees, and numerous other residents. On 08/05/2026 at 08:10 AM, Administrative Nurse D verified that LN G should not administer insulin injections in public areas and that residents should be taken to their rooms or a private area. The facility's Respect and Dignity; Right to Personal Property policy, dated August 2026, stated residents have the right to be treated with respect and dignity.
Late Meal Service and Public Medication Administration
Penalty
Summary
Facility staff failed to promote dignity and respect for Resident 3 when the resident’s lunch tray was not served with the other residents in the dining room on 7/30/2026 and again on 7/31/2026. Resident 3 was admitted with diagnoses including dementia, major depressive disorder, and anxiety, and the MDS indicated the resident had moderately impaired cognitive skills for daily decision making and required supervision or substantial assistance with multiple activities of daily living. During observation, Resident 3 was seated at a dining table with other residents while the other residents were eating, but Resident 3 had no lunch tray present. During the first observation, Treatment Nurse 1 verified that Resident 3 had no lunch tray and was watching the other residents eat, and stated he did not know why the tray was not included with the others. The Assistant DON later stated the resident was not served lunch on time and should have been served between 12:00 PM and 12:15 PM with the other residents in the dining room. On the second day, Resident 3 was again observed seated at the dining table at 12:15 PM with no lunch tray while other residents were eating. The DON and Dietary Supervisor stated the delay left the resident waiting while others ate, and the Dietary Supervisor stated the system for getting the dining room resident list to the kitchen staff was not working. Facility staff also failed to maintain Resident 4’s dignity during medication administration in the dining room. Resident 4 was admitted with diagnoses including mood disorder, intellectual disability, and cerebral palsy, and the MDS indicated the resident required substantial assistance with several activities of daily living. During observation, LVN 1 administered oral medication to Resident 4 in the dining room while wearing gloves. Treatment Nurse 1 stated medication should not be given in a public area and that the resident should have been assisted back to the room for private medication administration. The DON stated the resident could feel disrespected and that other residents might think the resident had an infectious disease because staff wore gloves while giving the medication.
Unauthorized Shaving of Resident's Beard
Penalty
Summary
The facility failed to ensure that two CNAs did not shave the beard of one resident without the resident's RP's consent. The resident had diagnoses including dementia and Alzheimer's disease, and his MDS indicated his cognition was moderately impaired and that he was dependent on facility staff for ADLs. The resident's RP stated that the beard was shaved without her knowledge or consent and that the resident had worn his beard for many years and she had never seen him without it. The DON stated that the RP should have been notified before the resident's beard was shaved because the resident did not have capacity to make decisions for himself. The DON also stated that CNA 1 and CNA 2 reported the resident looked unkempt and dirty on admission and that they felt he needed grooming. The facility policy on resident preferences stated staff should ask the resident and, when appropriate, the resident representative about preferences upon admission before initiation of treatment/therapy and/or during the initial IDT meeting, including preferences related to grooming.
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