Meal Service Not Coordinated to Preserve Resident Dignity
Summary
Resident 147 was observed in the Tuolumne dining room on 3/3/26 without a meal while other residents at the table had already been served. Resident 147 had diagnoses including UTI, Parkinson’s disease, and a right hand fracture, and his MDS showed a BIMS score of 6, indicating severe cognitive impairment. During the observation, CNA 3 stated Resident 147 had been transferred from the Olive room to the Tuolumne room days earlier and that his trays had been late since the transfer. Resident 147 stated he was hungry and tired of his food being late, and Resident 77 stated his meals had been late every day since he transferred. Resident 147’s lunch tray was not delivered until 24 minutes after the other residents in the Tuolumne dining room had received their meals. At the time of delivery, his meal ticket still listed the Olive room, and the dining location had not been updated. The DSD stated the dining room change had been completed on 2/26/26 for a start date of 2/27/26, but the meal ticket had not been processed and updated. The DSD stated the result was that Resident 147’s meals were delivered to the wrong dining room since 2/27/26, causing him to watch others eat before receiving his own meal and to dine alone. Resident 40 was observed in the Olive dining room without his lunch tray while other residents had already been served. Resident 40 had diagnoses including fracture of the neck of the left femur, atherosclerosis, atrial fibrillation, muscle weakness, dementia, and heart failure, and his MDS showed a BIMS score of 8, indicating moderate impairment. CNA 3 stated Resident 40 gave his lunch tray to Resident 58 when Resident 58’s tray was not brought to her, and CNA 3 did not check to ensure Resident 58 had received the correct tray. CNA 3, CNA 1, RNA 1, and the DON all stated residents should have been served at the same time and staff should have checked trays to ensure the correct diet was served to the correct resident.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with chronic respiratory failure, COPD, oxygen dependence, anxiety, and insomnia was denied permission to bring in a personal recliner chair despite needing it to breathe better and elevate swollen legs. The resident slept in a manual wheelchair because lying flat caused SOB and fear of severe desaturation, while family and a friend reported the resident wanted the chair from home but was told no because it was not leather or was a fabric infection control concern. Staff confirmed the resident had been sleeping in the wheelchair since admission and that the resident wanted a recliner that could be operated independently.
A facility failed to protect residents’ dignity and personal space when an aide wore a Bluetooth earpiece while redirecting a resident with dementia and entered another resident’s room while still speaking into it. The facility also stored a roommate’s oxygen equipment and laundry basket in a blind resident’s allotted space, cluttering her room and limiting her usable area. The DON and ADM stated staff were prohibited from using phones, earpieces, or headphones while on duty, and the room setup was acknowledged as violating the resident’s right to her space.
Failure to Provide Access to Personal Property After Room Change: A cognitively intact resident with DM2, muscle weakness, dysphagia, venous insufficiency, and mobility/ADL impairments was moved to a new room after an altercation with a roommate, but his belongings were left in the old room for over a week. The resident said he asked staff daily for his items, and housekeeping confirmed the belongings had not been moved when expected.
Failure to Protect and Inventory Residents’ Personal Belongings: The facility did not protect residents’ clothing and personal items or follow its policy to inventory and update personal property records. One resident with severe cognitive impairment had multiple missing items that remained unresolved, while other residents with intact or near-intact cognition reported missing clothing or a hair clipper that were not reported or documented. Staff observed unlabeled resident clothing in the laundry area, and the MRD confirmed missing or absent inventory records for some residents.
A resident with Parkinson's disease, chronic respiratory failure with hypercapnia, and fibromyalgia was sent to an outside appointment wearing a hospital gown instead of being appropriately dressed. A CNA said she thought the resident was being prepared for a cot transfer, left the resident in the gown with a blanket, and did not place footwear on the resident because of a foot dressing and brace. The RN ADON later confirmed awareness that the resident had gone out in a hospital gown.
Failure to document an itemized personal property inventory for a resident on admission. A resident with multiple diagnoses, including vascular dementia with psychotic disturbance, reported bringing six boxes and four suitcases of belongings that were stored outside her room, and she stated staff never reviewed the contents with her. The inventory listed containers and a few items, but did not identify the contents of each box or luggage and was not signed by the resident or staff; the DON stated the admitting RN was responsible for completing the inventory.
Failure to Allow Resident to Use Personal Recliner Chair
Penalty
Summary
The facility failed to ensure Resident 50 was allowed to retain and use personal possessions, specifically the resident’s own recliner chair, as space permitted and unless medically contraindicated. Resident 50 was admitted with chronic respiratory failure with hypoxia, COPD, oxygen dependence, anxiety, and insomnia. The admission social services evaluation indicated the resident slept in a wheelchair because it helped with breathing, and the admission MDS showed the resident was cognitively intact, had shortness of breath when lying flat, and was at risk for pressure ulcers. A cardiology follow-up note later documented continued leg swelling and that the resident had not yet received a recliner chair that was supposed to be provided. Resident 50 and the resident’s daughter asked about needing a reclining chair at a care conference, and the business office and administrative staff were to look into purchasing one. However, multiple observations showed the resident sitting in a non-reclining manual wheelchair while awake and asleep, and the resident stated the wheelchair was used 24 hours a day, 7 days a week since admission. The resident reported not sleeping in bed because of shortness of breath and fear that oxygen levels dropped into the 70s when lying down, and also stated it was difficult to elevate the legs while sitting in the wheelchair. The resident, family, and a friend stated the resident had requested to bring the resident’s own recliner chair from home, but the request was denied because the chair was not leather or was made of fabric and was considered an infection control concern. Staff confirmed the resident had been sleeping in the wheelchair since admission, that the resident had edema because the legs were not properly elevated, and that the resident wanted the personal recliner because it could be operated independently. The administrator confirmed he denied the request, acknowledged there was adequate space in the room and no other residents’ rights would be infringed upon unless the chair became unsanitary, and stated no additional follow-up was conducted after the denial.
Dignity and Personal Space Violations
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity and to protect their right to retain and use personal possessions and furnishings as space permits for three residents. The report identified concerns involving two residents with cognitive impairment and one resident whose room space was cluttered with another resident’s equipment. The facility policy stated employees shall treat all residents with kindness, respect, and dignity and that residents have the right to retain and use personal possessions to the maximum extent that space and safety permits. Resident #19 was an older female admitted with Alzheimer’s disease and mood disorder due to a known physiological condition. Her quarterly MDS reflected a BIMS score of 11, indicating moderate cognitive impairment, and her care plan addressed impaired social interaction with redirection, structured routines, and calm boundary-setting. Resident #8 was an older female with hemiplegia and hemiparesis, cognitive communication deficit, mood disorder, anxiety disorder, and need for assistance with personal care. Her quarterly MDS reflected a BIMS score of 12, indicating moderate cognitive impairment, and her care plan addressed impaired cognitive functioning after a stroke with interventions to assist with memory, decision making, safety, orientation, and dignity. During observation, NA K stood in the hall where Residents #19 and #8 lived while wearing a Bluetooth earpiece and talking very quietly and quickly. Resident #19 approached him with paper towels, and he took the towels from her and disposed of them while still speaking into the earpiece. He then told her to go to her room and continued speaking into the earpiece before and after addressing her. Resident #19 appeared angry, and another staff member later directed her to an activity. NA K then walked into Resident #8’s room and stood just inside the doorway talking quietly for about 30 seconds while Resident #8 did not respond. In interview, NA K stated he had worked at the facility for one month, had training on redirecting residents with dementia, and knew it was not acceptable to use the phone while working. He said the Bluetooth earpiece was for English lessons and that he did not mean to be disrespectful. The DON and ADM stated staff were trained to be respectful, that cell phones, earpieces, and headphones were prohibited while on duty, and that such use could cause residents to feel like they were not listened to. Resident #25 was an older female with seizures, cerebral palsy, legal blindness, need for assistance with personal care, muscle weakness, lack of coordination, drug-induced secondary parkinsonism, and muscle spasm. Her care plan stated her bed should be placed against the wall, her personal items should remain accessible, her environment should not be rearranged to enable recognition of objects, and her room should be kept clutter free due to fall risk. Observation and interview showed that her room space contained an oxygen cylinder, an oxygen concentrator, and a laundry basket belonging to her roommate. The FM stated the items were stored in Resident #25’s space for convenience, and LVN B stated the equipment was facility property and should have been placed in the designated area for the roommate. LVN B also stated the setup violated Resident #25’s right to have her allotted space because the items cluttered her area. The DON stated the items diminished the usable space designated for Resident #25 and that alternative arrangements would be needed so she could fully utilize her space.
Failure to Provide Access to Personal Property After Room Change
Penalty
Summary
The facility failed to provide a resident access to personal property after the resident was moved to a different room following an altercation with a roommate. The resident was admitted on 6/27/2025 with diagnoses including type 2 diabetes mellitus, muscle weakness, dysphagia, and venous insufficiency, and the MDS dated 3/13/26 documented a BIMS score of 15/15, indicating the resident was cognitively intact. The same MDS documented bilateral leg impairment, wheelchair use for locomotion, dependence on staff for toileting, and substantial to maximum assistance needed for showers and dressing. The resident stated that about a week before the interview, he was moved to a new room on a different hall because he and his roommate got into a fight, but his belongings were not moved with him and he had been without access to them for over a week. The resident said he had asked staff every day to bring his belongings to his new room. The medical record documented the altercation and temporary room move on 5/11/2026. Housekeeping staff confirmed the resident had moved to a different hall and that his belongings were still in the old room; one housekeeper said she would move them later, while another stated belongings should have been moved the same day and that this is usually how it is done. The resident's belongings were observed still in the old room before later being observed in the new room. The facility's admission contract states residents have the right to keep and use their own property and to have a safe place for small valuables that can be accessed daily.
Failure to Protect and Inventory Residents’ Personal Belongings
Penalty
Summary
The facility failed to protect residents’ personal belongings and did not follow its policy to inventory and document personal property upon admission and update it as needed. Four sampled residents were involved: one resident with severe cognitive impairment, two residents with no cognitive impairment, and one resident with intact cognition. The deficiency was based on observation, interview, and record review showing missing clothing and personal items, incomplete or absent inventories, and unresolved concerns about laundry and lost belongings. For one resident with diagnoses including stroke with hemiparesis and hemiplegia, dementia, and depression, the responsible party reported that many items were missing and had to be replaced. The resident’s personal effects inventory listed clothing and personal items, but multiple later handwritten missing-item lists showed blankets, pants, shirts, socks, and other belongings that were not found. The grievance record stated that not all items had been found and that the issue remained unresolved. During observation in the laundry area, staff acknowledged that residents’ clothing was still mixed together, many items had no names or labels, and there were ongoing issues with residents’ personal clothing. Two other residents with BIMS scores of 13 stated they were missing personal items but had not reported them. One resident said a hair clipper was missing, and the medical record director confirmed it was not on the admission inventory and the inventory had not been updated. Another resident reported missing clothing and said the second set of clothes provided by family was also stolen, while the medical record director confirmed there was no inventory record in either the electronic record or hard chart. A fourth resident with intact cognition stated socks were missing from laundry and that the concern raised in the resident council meeting had not been resolved. The medical record director also provided an inventory for this resident dated after admission, but the admission inventory was not provided. The facility policy stated that residents’ personal belongings and clothing are to be inventoried and documented upon admission and updated as necessary, and the resident rights policy stated residents may retain and use personal possessions to the maximum extent space and safety permit.
Resident Sent to Appointment in Hospital Gown
Penalty
Summary
Resident #3 was sent to an outside appointment wearing a hospital gown rather than being appropriately dressed. The resident had diagnoses including Parkinson's disease, chronic respiratory failure with hypercapnia, and fibromyalgia, and the quarterly MDS indicated the resident was unable to complete the interview. A progress note documented that the resident was out on an appointment and had no distress at the time of the appointment. A CNA stated she had been told to get the resident dressed and ready for the appointment, but believed the resident was getting a cot transfer and therefore left the resident in a gown, placing a blanket over the resident and tying the gown. The CNA also stated she did not place a shoe or sock on the resident because of a dressing on the foot with a brace. In a separate statement, the CNA said she had been told not to change the resident's clothing or hair wraps if the resident had not had a bed bath, and she did not want to put clean clothing on the resident because the bed bath days were on night shift. An RN ADON later confirmed awareness that the resident had been sent out in a hospital gown.
Failure to Document Itemized Personal Property Inventory
Penalty
Summary
The facility failed to document an itemized list of personal property for one of three sampled residents upon admission. Resident 2 was admitted with diagnoses including polyneuropathies, chronic pain syndrome, anxiety, major depression, opioid dependence, vascular dementia with psychotic disturbance, and was documented on the MDS as cognitively intact with a BIMS score of 14. The MDS also showed Resident 2 required supervision with eating, oral hygiene, and upper body dressing, moderate assistance with toileting, and substantial/maximal assistance with transfers from bed to chair, toileting, and showering. During a concurrent observation and interview, Resident 2 stated she had brought six boxes and four suitcases of belongings that the facility stored outside her room in a separate closet, and she reported missing items including a second set of bed sheets and pillowcases, a TV screen, and a small white box with jewelry valued at forty thousand dollars. Resident 2 stated staff never reviewed the contents of her boxes and suitcases to record exactly what she had upon admission. The Inventory of Personal Effects listed 12 boxes, four luggage cases, one black plastic bag, two bedside plastic drawers, a cellphone, and a tablet, but did not identify the individual items in each box or luggage and was not signed by staff or Resident 2. The DON stated the admitting RN was responsible for completing the inventory on admission and that each box should be opened and confirmed with the resident.
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