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.
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.
Dignity and Privacy Failures in Toileting and Catheter Care: Two residents were not treated with dignity during toileting and catheter care. One resident who needed a bowel movement was told by staff to lie in bed, use the bathroom on herself, and then be changed, even though the DON said a bedpan should have been offered. Another resident’s urinary catheter drainage bag was observed hanging without the ordered privacy cover, and an LPN confirmed the cover should have been in place for privacy.
Residents reported that an LPN was rude, pushy, snappy, and condescending during medication passes and other interactions, with one resident saying the nurse refused to let him take meds after eating and stayed in his room until he complied. Six cognitively intact residents raised the same concern, and the Resident Council President said residents believed reporting the issue would not help because staff would side with the nurse. The DON stated this behavior was a serious violation of resident dignity and respect, and the Administrator acknowledged prior reports about the LPN.
The facility failed to protect residents’ right to a dignified and comfortable environment when it did not effectively manage one cognitively impaired resident’s ongoing nighttime yelling, which repeatedly disrupted the sleep of two cognitively intact residents. Staff, including a CNA, the DON, and the Administrator, were aware that this resident, diagnosed with dementia and psychosis, frequently yelled and screamed at night while often sleeping during the day. Progress notes documented nighttime hollering, and interviews confirmed that the disruptive behavior persisted over time, interfering with other residents’ ability to rest.
Surveyors found that the facility failed to protect two residents’ rights to dignity and privacy during routine care. One resident, with moderate cognitive impairment and dependent for toilet hygiene, was observed receiving incontinence care while uncovered, with the room door open and the privacy curtain only partially drawn, allowing visibility into the hallway despite facility policy requiring full privacy. Another resident, dependent for eating and with hemiplegia after a stroke, was assisted with lunch by a CNA who stood over the resident instead of sitting at eye level as required by the facility’s feeding skills checklist. Staff interviews, including with CNAs, an LPN, the DON, and the Administrator, confirmed that existing policies and in-service training directed staff to provide privacy during incontinence care and to sit beside residents when assisting with meals to ensure dignified care.
Failure to Provide Privacy During Insulin Administration: An LPN performed an accucheck and administered NovoLog insulin to a resident without closing the door or pulling the privacy curtain, while staff and other residents passed in the hallway. The resident had Type 2 DM and moderately impaired cognition, and both the LPN and DON confirmed that privacy should have been provided to protect the resident's dignity.
Failure to preserve resident dignity during personal care and catheter care. A resident with paraplegia had an uncovered urinary catheter bag visible from the hallway, another resident with hemiplegia reported wanting a shave and haircut but said staff did not provide it, a resident with severe cognitive impairment was shaved in the common dining area with others present, and another resident with paraplegia had an uncovered catheter bag visible from the doorway. Staff and the DON confirmed catheter bags should have privacy covers and that shaving should not occur in common areas.
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