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:
Failure to Provide Dignified Feeding Assistance: A resident with cognitive impairment, depression, and vascular dementia was observed being assisted with breakfast by a CNA who was standing over her. The CNA described dignity measures during feeding, and the DON stated staff are expected to sit at eye level rather than stand when assisting residents with meals. The facility’s Dignity policy required residents to be treated with dignity and respect and to receive a dignified dining experience.
Failure to Treat Resident with Dignity and Respect: A resident with dementia with agitation, TBI, and PTSD was reportedly spoken to in a demeaning and profane manner by a CNA during care after becoming upset and requesting a shower following bowel incontinence. A second CNA witnessed the exchange, and the DON’s interview summary reflected the resident reported being called an idiot and hearing profanity used by the CNA.
A resident with an indwelling suprapubic catheter was observed in bed with an uncovered urinary drainage bag lying on the floor beside the bed and visible from the hallway. The resident’s care plan called for a dignity bag to cover the urine bag each shift and for the catheter bag and tubing to be positioned below the bladder and away from the room entrance, but the bag remained uncovered during repeated observations. An LPN confirmed the bag was visible and could not explain why staff did not cover it after the resident returned from a recent urology visit with a different drainage bag.
Failure to Treat Resident with Dignity: A CNA responded inappropriately after a resident with dementia struck her during care, telling the resident, "If you hit me, I will hit you back." The resident's family member heard the remark and became upset. The ADM verified the CNA was suspended and stated residents must be treated in a safe, helpful, and dignified manner.
Missing Personal Property Not Inventoried or Tracked: A resident with intact cognition and multiple chronic conditions had a wedding ring and fur coat go missing, but the facility had no completed personal property inventory, no dedicated missing-items log, and no documented investigation or objective evidence showing where the items went. The DON confirmed nursing staff did not itemize the resident’s belongings, and the administrator could not provide transfer records, transport checklists, or other documentation to account for the missing property.
A resident with left hemiplegia, vascular dementia, and anxiety disorder was not treated with dignity and respect during incontinent care when a CNA was rude and rough while attempting to position her. The resident repeatedly called for help and asked for the CNA to be removed from the room, and another CNA completed the care after the first CNA left. A nurse and CNA both heard the resident complain that the CNA was rude and mean, and the resident later reported the care had been rough.
Failure to Provide Dignified Feeding Assistance
Penalty
Summary
The facility failed to ensure that Resident 2 was cared for in a manner that promoted and enhanced her wellbeing, sense of self-worth, and self-esteem, according to the facility’s Dignity policy. Resident 2 was admitted and later readmitted with diagnoses including hypotension, major depressive disorder, and vascular dementia. Her MDS dated 6/21/2026 indicated that she was cognitively impaired and required setup/clean up to dependence on staff assistance with ADLs. During an observation on 7/29/2026 at 8:05 A.M., a CNA was seen standing over Resident 2 while assisting her with breakfast in her room. During an interview shortly afterward, the CNA stated that dignity during feeding includes ensuring the resident swallows, keeping the head of bed high, making sure the resident is comfortable, and providing privacy. The DON later stated that staff are expected to sit at eye level with residents when assisting with eating, rather than standing, for dignity and respect. 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 to be treated with dignity and respect at all times.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
The facility failed to ensure a resident with dementia with agitation was treated in a dignified and respectful manner when a CNA allegedly responded to the resident in a demeaning and derogatory way during care on the evening shift. The resident had diagnoses including dementia with agitation, traumatic brain injury, and PTSD, was wheelchair-bound, and depended on staff for mobility and ADLs. The resident’s behavior care plan directed staff to approach him/her in a calm and reassuring manner during episodes of increased anger or agitation. According to the facility’s report and witness statements, the resident was agitated after an episode of bowel incontinence and was yelling that he/she wanted a shower. A CNA allegedly told the resident to stop yelling like an idiot. After the shower, the resident complained that staff had taken too long to assist, and when the CNA explained she had been helping another resident, the resident responded with profanity. The CNA allegedly replied, well, fuck you too. A second CNA witnessed the exchange and later confirmed the statements, and the DON’s written summary of the resident interview indicated the resident reported being called an idiot and hearing profanity used by the CNA.
Uncovered Urinary Catheter Bag Visible From Hallway
Penalty
Summary
The facility failed to implement measures in the resident’s plan of care and standards of nursing practice to promote dignity for a resident with an indwelling urinary catheter. During a tour, the resident was observed lying in bed with the bedroom door open and a urinary catheter bag containing a moderate amount of urine lying on the floor beside the foot of the bed, visible from the hallway. The resident appeared to be asleep and did not respond when the surveyor knocked on the door. Record review showed the resident had a plan of care for an indwelling catheter and an indwelling suprapubic catheter, with interventions including applying a dignity bag to cover the urine bag every shift and positioning the catheter bag and tubing below the level of the bladder and away from the room entrance. A later observation showed the uncovered urinary catheter bag remained in the same location and was still visible from the hallway. An LPN confirmed she was the nurse providing care, stated that aides and nurses empty and maintain urinary bags, and acknowledged the bag was uncovered. She also explained that the facility used bags with a panel to prevent contents from being visible, but the resident had returned from a recent urology appointment with a different drainage bag that did not include a dignity cover, and she could not explain why staff did not cover it after the resident returned.
Failure to Treat Resident with Dignity
Penalty
Summary
The facility failed to ensure that one of three sampled residents was treated with respect and dignity when a CNA responded inappropriately during care. While providing care to a resident with diagnoses of dementia and difficulty with daily tasks, the resident punched the CNA in the chest. The CNA told the resident, "If you hit me, I will hit you back," and the resident's family member was in the room and heard the comment. The CNA stated the resident was aggressive at times, that the incident hurt and frightened her, and that the family member became upset, yelled at her, and demanded to speak with a supervisor. The Administrator verified that the CNA was suspended because of her action toward the resident and stated that all residents must be treated in a safe, helpful, and dignified manner.
Missing Personal Property Not Inventoried or Tracked
Penalty
Summary
The facility failed to maintain an accurate personal property inventory and failed to safeguard a resident’s personal belongings. The resident was an older female with diagnoses including atrial fibrillation, bradycardia, chronic gout, and stage 4 chronic kidney disease, and she was wheelchair-dependent. Her MDS assessment documented a BIMS score of 15 out of 15, indicating intact cognition. The deficiency involved her missing wedding ring and fur coat, with no completed or provided itemized personal property inventory upon admission or during her stay. Survey interviews and record review showed the facility did not maintain a dedicated missing items log and instead used only a general concern/complaint log, which contained no entry for the missing ring or coat. The administrator could not provide an inventory sheet, missing property investigation, transfer logs, hospital transport checklists, or any other documentation to show the items left the facility with the resident during a hospital transfer. The resident stated that staff did not provide an inventory list on admission and that there was no established protocol, inventory log, or tracking method for missing personal items. The DON confirmed nursing staff failed to document or itemize the resident’s belongings on an inventory sheet or official record, and the record contained no documented inventory form, investigative report, missing item log, or follow-up entries regarding the missing items.
Rude and disrespectful incontinent care
Penalty
Summary
The facility failed to ensure one of four sampled residents was treated with dignity and respect during incontinent care when CNA A interacted with the resident in a rude and disrespectful manner. The resident was admitted with diagnoses including left hemiplegia following cerebral infarction, vascular dementia, and an anxiety disorder. The MDS dated 06/2026 indicated a BIMS score of 14, and Section E documented no hallucinations, delusions, psychosis, rejection of care, wandering, or behavioral symptoms directed toward others. During an interview, the resident stated CNA A was rude while providing incontinent care and attempted to turn her onto her left side after she repeatedly stated she could not tolerate that position. The resident stated she repeatedly called for help and requested that CNA A be removed from the room, after which another CNA entered, CNA A left, and the care was completed. CNA B stated he heard the resident repeatedly calling for help and for Licensed Nurse B, entered the room, and heard the resident say, "Get this woman off of me" and describe CNA A as rude and mean. Licensed Nurse B stated the resident had been at her normal baseline before the incident and later reported CNA A had been rough during incontinent care. The Social Services Director stated the resident normally communicated her needs appropriately and did not typically make complaints regarding staff. The SBAR dated 7/06/26 documented the resident reported CNA A had been rough while providing incontinent care.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release October 8, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.