Dignified Medication Administration Not Maintained
Summary
The facility failed to provide a dignified experience for 1 of 2 residents, R20, during medication administration. R20’s records showed severely impaired cognition, inattention, disorganized thinking, verbal behaviors toward others, and diagnoses including severe dementia with psychotic disturbance, visual hallucinations, generalized anxiety disorder, PTSD, and delusional disorder. Her care plan identified mood, behavior, and sleep alterations related to Alzheimer’s disease, dementia, generalized anxiety disorder, paranoia, public outbursts, and accusations that people were throwing medications down her throat, and it directed staff to redirect and reapproach when she was resistive or combative, use a calm approach, provide reassurance, and offer comfort items. During observation, RN-A brought medications to R20 in the dining room and attempted to pour them from a small plastic cup into her mouth. When R20 removed one medication, Divalproex, and threw it on the floor, RN-A attempted again to pour the remaining medications into her mouth while R20 moved her head back and forth and tried to pull away. RN-A then raised her voice, stated the resident’s name, told her she needed to take her medications, pulled her chair back from the table, picked up the Divalproex from the floor, placed it in a separate cup, and asked why she would not take her medications. R20 responded that it was because the nurse was not being nice. RN-A then left with the remaining refused medications and stated R20 would take them later and that she always had a behavior when taking her morning medications.
Penalty
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A resident with hemiplegia, dysphagia, dementia, and an ADL self-care deficit was care-planned to receive partial assistance from one staff member for eating and was dependent on staff for meals. While about 13 residents were in a secured dining area awaiting breakfast, a CNA, from the hallway, loudly referred to the resident as a “feeder” to another CNA in the dining room, in front of other residents. The CNA later confirmed she had used this term and acknowledged it was not dignified or respectful, contrary to the facility’s resident rights policy requiring staff to treat residents with kindness, respect, and dignity.
Two residents with intact cognition and multiple medical conditions, including dysphagia, hemiplegia, dementia, and depression, were observed being fed breakfast in bed by CNAs who stood beside them rather than sitting, despite a facility policy requiring meal assistance to meet individual resident needs. In one case, an LPN confirmed a chair was available but not used; in the other, the CNA reported no chair was present in the room. These observations led surveyors to determine that residents were not provided with dignity during meals.
A severely cognitively impaired resident, fully dependent for ADLs and with multiple medical conditions, was observed seated alone in the dining room wearing only a hospital gown that left the back and legs exposed, with a full breakfast tray in front of him that he was not feeding himself. A CNA acknowledged bringing the resident to the dining room in the gown due to time and staffing constraints and recognized this was not appropriate but did not further cover the resident. An LPN stated it was acceptable for residents to be in the dining area in hospital gowns, despite the resident’s inability to choose his attire. This situation conflicted with the facility’s written policy requiring that residents be treated with dignity, respect, and privacy.
Staff unlocked and searched a resident's locked nightstand drawer without the resident present or obtaining consent, removing a vape pen from inside. The Maintenance Director provided the key and unlocked the drawer at the request of the UM, who then took the vape pen, while an OTA was also present. The OTA had previously reported the vape pen to therapy leadership and informed the UM but did not seek the resident's permission to search or retrieve items, and the resident did not request that staff retrieve anything. The DON later discovered the vape pen on their desk and had not discussed the search with the resident. The facility's smoking policy states that monitoring residents' rooms and belongings for smoking materials must be done in a way that does not violate resident privacy.
The facility failed to ensure a dignified dining experience for three cognitively impaired residents on puree diets who required staff assistance with eating. During a lunch meal, a CNA stood while feeding all three residents seated at the same table, rather than sitting at eye level as required by facility policy. The CNA acknowledged she should have been seated but stated she stood so she could reach all three residents, and the DON confirmed that standing over residents during feeding was a dignity concern and inconsistent with the facility’s feeding practices policy.
A resident with intact cognition and a history of mental health and medical conditions was served meals on disposable dishware and utensils without clear justification or reassessment, despite facility policy limiting such use to emergencies. Both the resident and staff were unaware of the reason for this intervention, and the Dietary Director confirmed that the practice had not been reviewed for continued appropriateness.
Failure to Maintain Resident Dignity During Dining Assistance
Penalty
Summary
The deficiency involves a failure to maintain resident respect and dignity in accordance with resident rights and facility policy. Resident #5, who had diagnoses including hemiplegia and hemiparesis following cerebral infarction, dysphagia, and dementia without behavioral disturbance, was admitted on an unspecified date. A comprehensive MDS assessment dated 04/15/26 documented that the resident was rarely or never understood and was dependent on staff for eating. The revised care plan dated 04/01/26 identified an ADL self-care performance deficit and included an intervention for partial assistance of one staff member to eat. On 04/14/26 at 8:22 A.M., surveyors observed approximately 13 residents in the secured unit dining area awaiting breakfast while CNA #110 passed out breakfast trays. As CNA #110 exited the secured unit, she turned back from the hallway and yelled to another CNA in the dining room that Resident #5 was a “feeder,” referring to the resident’s need for assistance with eating. During an interview at 8:35 A.M. the same day, CNA #110 confirmed she had yelled out that the resident was a feeder and acknowledged that referring to the resident in this manner was not dignified or respectful. Review of the facility’s Residents Rights policy, dated 02/20/26, stated that care team members would treat each resident with kindness, respect, and dignity, which was not followed in this instance.
Failure to Maintain Resident Dignity During Assisted Meals
Penalty
Summary
The deficiency involves failure to ensure residents were provided dignity during meals, specifically by not being seated while feeding residents who had intact cognition. One resident with osteomyelitis of the vertebra, dysphagia, generalized anxiety disorder, dementia, heart failure, unspecified psychosis, anemia, and a history of stroke and venous thrombosis/embolism was admitted on a specified date and had physician orders for a regular diet with mechanical soft texture and nectar thickened liquids. The resident’s MDS assessment showed intact cognition. During an observation, a CNA was seen standing beside the resident’s bed while feeding eggs, hashbrowns, and oatmeal. An LPN confirmed there was a chair available in the room that could have been used to sit while assisting the resident with the breakfast meal. Another resident, admitted with hemiplegia, major depressive disorder, and vascular dementia, had physician orders for a regular diet with regular texture and thin liquids, and an MDS assessment indicating intact cognition. During a separate observation, a CNA was seen standing beside this resident’s bed while feeding eggs, hashbrowns, and oatmeal. The CNA confirmed there was no chair in the resident’s room to sit down and assist with the breakfast meal. Review of the facility’s “Assistance with Meals” policy, revised July 2017, stated that residents shall receive assistance with meals in a manner that meets the individual needs of each resident. The survey findings were investigated under two complaint numbers and determined that the residents were not provided with dignity during meals.
Resident Dignity Not Maintained When Brought to Dining Room in Exposing Hospital Gown
Penalty
Summary
Surveyors identified a failure to protect a resident’s dignity when a severely cognitively impaired memory care resident was observed seated alone in the dining room wearing only a hospital gown, with his back and legs exposed. The resident had multiple medical diagnoses including unspecified dementia, psychosis, delusional disorder, TIA, depression, anxiety, and significant physical limitations such as muscle weakness, difficulty walking, and unsteadiness. His most recent MDS showed a BIMS score of 0, highly impaired vision, unclear speech, and dependence on staff for all ADLs, including dressing, toileting, and eating. At the time of observation, he had a full breakfast tray in front of him but was not feeding himself. A CNA confirmed that the resident had been brought to the dining room in the hospital gown and stated there was not enough time or staff to get him dressed before breakfast, acknowledging that this was not appropriate attire for the dining room but leaving him uncovered. An LPN reported she believed it was appropriate for residents, particularly skilled residents, to be in the dining area in hospital gowns, while also acknowledging that this resident could not choose how he was dressed due to his cognitive impairment. The resident’s spouse stated she believed staff did everything they could given staffing ratios and that responses could be delayed because staff were busy. The facility’s Dignity, Respect, and Privacy Policy stated that residents were to be treated with respect and cared for in a manner that protected their privacy, but this was not followed in this incident.
Failure to Obtain Resident Consent Before Searching Locked Personal Belongings
Penalty
Summary
A resident with COPD with acute exacerbation and tobacco use, admitted on 11/15/25, had a locked nightstand drawer containing a vape pen. On 03/02/26 at 11:27 A.M., the Maintenance Director entered the resident's room with the Unit Manager (UM) and an Occupational Therapy Assistant (OTA) present near the bedside stand. The Maintenance Director unlocked the resident's locked nightstand drawer and the UM removed the vape pen from inside. The resident was not in the room or nearby at the time. The UM confirmed removing the vape pen from the locked drawer and acknowledged that the resident was not present and that she did not obtain the resident's consent to search the property. The Maintenance Director confirmed providing the key, that the drawer was unlocked at the UM's request, and that no consent was obtained from the resident. The OTA reported notifying the Director of Therapy and verbally informing the UM that the resident had a vape pen, and confirmed the resident was not in the room when the vape pen was removed. The OTA further confirmed they were not asked by the resident to retrieve anything from the nightstand and did not ask the resident for consent to search the property. The DON stated they were unaware at the time that the resident's property had been searched and later found the vape pen on their desk with a note, and confirmed they had not spoken with the resident about the search. The resident reported that staff took the vape pen from the locked drawer while the resident was at therapy and confirmed that no one asked for consent to search the property or to retrieve anything from the room. Facility policy on resident smoking states that staff will monitor rooms and belongings of residents who smoke for smoking materials in a manner that does not violate the resident's right to privacy.
Failure to Provide Dignified Dining Assistance in Memory Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure a dignified dining experience for three residents on the memory care unit who required staff assistance with eating. All three residents had dementia, severely impaired cognition per their MDS assessments, and were on puree diets; two were documented as dependent on staff for eating, and one required staff assistance. During a lunch meal observation in the memory care dining room, the three residents were seated at the same table with their meal trays in front of them while a CNA provided eating assistance. Surveyors observed that the CNA stood while assisting all three residents with eating rather than sitting at eye level as required by the facility’s “Resident Dignity and Feeding Practices” policy. In interview, the CNA confirmed she was standing and acknowledged she should sit beside residents when assisting with eating, explaining she stood because she could not reach all three residents if seated. The DON also confirmed that the CNA should have been seated while providing eating assistance and stated that standing over residents during feeding was a resident dignity concern, consistent with the facility’s policy that staff should sit at eye level with residents during feeding.
Failure to Provide Appropriate Dishware and Silverware to Promote Resident Dignity
Penalty
Summary
The facility failed to ensure that a resident was provided with appropriate dishware and silverware to promote dignity during meals. Record review showed that the resident, who had diagnoses including major depressive disorder, essential hypertension, and generalized anxiety disorder, was cognitively intact and had been receiving disposable dishware and utensils. The use of disposables was originally implemented due to the resident discarding smokeless tobacco into mugs and bowls, but there was no evidence of reassessment to determine if this intervention was still necessary. The resident's care plan indicated a risk for malnutrition, and the use of disposables was discontinued at a later date, but during the period reviewed, the resident continued to receive paper plates and plastic utensils without clear justification. Interviews with the resident and staff confirmed that the resident was unaware of the reason for receiving disposable dishware, and staff could not provide an explanation. The Dietary Director acknowledged that the intervention had been in place since the previous year and that no reassessment had occurred to determine if regular dishware and silverware should be reinstated. Facility policy stated that disposables should only be used in emergency situations, yet multiple residents, including the one reviewed, were receiving them outside of such circumstances.
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