Delayed Response to Call Lights and Resident Assistance Requests: Two cognitively intact residents reported prolonged waits for staff to answer call lights for toileting and brief changes, including waits of 30 minutes, 1.5 hours, and a prior delay until after lunch. During observation, a call light sounded for about 15 to 20 minutes while multiple nurses and CNAs walked past the room or remained at the nurses’ station without responding, despite facility policy requiring prompt response within 5 to 7 minutes.
Failure to Knock Before Entering Resident Room: A CNA entered a resident's room twice without knocking, despite facility policy requiring staff to knock, announce themselves, and protect privacy before entering. The DON confirmed this was the expected protocol, and the resident had severe cognitive impairment with a BIMS score of 03 and a history including cerebral infarction.
A facility failed to honor resident choice and dignity by routinely serving weekend meals in residents’ rooms instead of allowing dining room access. Residents and staff stated the dining room was closed or unavailable on Saturdays and Sundays because of staffing shortages, and one resident said he preferred the dining room for socialization but was required to remain in his room for all meals. The DON and Administrator were unaware the practice was occurring, despite the facility policy stating residents have the right to choice, privacy, and autonomy.
A facility failed to maintain dignity for two residents by leaving urinary catheter drainage bags uncovered and visible in their rooms. Both residents were cognitively intact and had urinary-related diagnoses; staff confirmed privacy bags were expected, but the bags were not consistently used when residents remained in their rooms, and the ADM acknowledged visitors could see the urine in the drainage bags.
Resident Exposed During Shower Care: A resident with severe cognitive impairment was observed sitting in a shower chair exposed from the waist up with the shower room door open and visible from the hallway. A CNA stated the door had been left open and the resident was not covered with a towel, while the DON confirmed the door should have been closed and the resident should have been covered to protect privacy and dignity.
Failure to Provide Knives During Meal Service: During a meal observation, several residents who were independent with eating were not given table knives and had to wait for staff to cut their meat. One resident stated the facility did not allow knives, and staff confirmed they had been told residents could not have a butter knife. The ADM and Interim DFD both stated residents capable of the task should receive a knife with meals to support a dignified dining experience.
A resident with a suprapubic catheter was exposed during catheter care when an LPN reentered the room without knocking and did not drape the resident for privacy, leaving the vaginal area exposed. Another resident requested help drying beneath her breasts after a shower, but a CNA refused, saying it was a private area; the resident remained wet and later had a red, raised rash beneath her breast. Staff interviews confirmed residents should be assisted with needed personal care and that privacy and proper draping are expected during care.
A resident with DM2 and OA stated she wanted alternate meal choices but did not know any were available and believed she had to eat whatever was served. Surveyors found that the daily menu and alternate meal options were not displayed on hallway TVs or on channel 2 of a resident room TV, and staff said they relied on those displays to inform residents of meal choices. The Dietary Manager and Administrator acknowledged that alternate menu options had not been consistently communicated and should be clearly posted so residents are aware of their choices.
Failure to maintain resident privacy during care: A resident was observed lying in bed uncovered with an incontinent brief and legs exposed while the privacy curtain was not drawn and the room door remained open to the hallway. Hospice personnel and maintenance staff passed by while the resident remained exposed. An CNA later confirmed she left the door open, and an LPN, DON, and the Administrator all stated the situation was not acceptable and that the resident's dignity should have been maintained. The resident had Major Depressive Disorder, CHF, and severe cognitive impairment.
Failure to Treat a Resident with Dignity and Respect: A CNA spoke rudely and in a disrespectful manner to a resident, including talking down to the resident and stating, “I told you that I was coming back to change you!” The resident’s family reported the incident, and the SSD and Administrator verified the CNA did not treat the resident with dignity and respect, contrary to facility policy requiring staff to treat residents with kindness, respect, and dignity.
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