Failure to Assist Resident with Dressing for Appointment
Summary
A facility failed to ensure that a resident was treated with respect and dignity by not assisting him with getting dressed in his personal clothing prior to leaving for a medical appointment. The resident, who had diagnoses including acute kidney failure, type 2 diabetes, and a colostomy, was cognitively intact and had 'street clothes' provided by a family member for the appointment. Despite this, the resident was sent to the appointment wearing a hospital gown, which led to feelings of embarrassment. The family member reported the incident, expressing concern about the resident's emotional well-being. Interviews and record reviews revealed that the CNA offered the resident the option to change into his clothes only once, and upon the resident's refusal, did not document the refusal or notify the charge nurse as required by facility policy. The facility's policies emphasized the importance of treating residents with dignity and supporting their rights, including the right to wear preferred clothing. There was no documentation in the clinical record of the resident's refusal or any communication to responsible parties regarding the incident.
Plan Of Correction
F-tag 557 1. Corrective Action for residents found to have been affected: • Resident 1 was discharged from the facility and admitted to Long Beach Memorial Medical Center on 5/30/2025. Resident did not return to the facility. DSD held a 1:1 verbal counseling with responsible CNA on 05/30/2025. The DSD started an in-service to staff including licensed vocational nurses and certified nurse assistants regarding the importance of maintaining resident respect and dignity by ensuring they are dressed in their own personal clothing when going out for an appointment, started on 05/30/2025. II. Facility's identification of other residents having the potential to be affected by the same deficient practice and corrective action taken: • On 6/18/2025, the DON conducted a visual audit of residents who went out for appointments to ensure they were dressed in their own personal clothing. On 6/18/2025, one resident went out for an appointment, and she was wearing her own personal clothing when she went to the appointment. No findings were identified. • The DSD started an in-service to staff including licensed vocational nurses and certified nurse assistants regarding the importance of maintaining resident respect and dignity by ensuring they are dressed in their own personal clothing when going out for an appointment, started on 05/30/2025. • The DSD conducted an additional in-service to certified nurse assistants regarding the importance of maintaining resident respect and dignity by ensuring they are dressed in their own personal clothing when going out for an appointment on 7/2/2025. • The DON conducted an additional in-service to licensed vocational nurses on 7/1/2025 regarding the importance of maintaining resident respect and dignity by ensuring they are dressed in their own personal clothing when going out for an appointment. III. Facility measures and systemic changes to ensure the deficient practice does not recur: The DSD started an in-service to staff including licensed vocational nurses and certified nurse assistants regarding the importance of maintaining resident respect and dignity by ensuring they are dressed in their own personal clothing when going out for an appointment, started on 05/30/2025. The DSD conducted additional in-service to certified nurse assistants regarding the importance of maintaining resident respect and dignity by ensuring they are dressed in their own personal clothing when going out for an appointment on 7/2/2025. The DON conducted an additional in-service to licensed vocational nurses on 7/1/2025 regarding the importance of maintaining resident respect and dignity by ensuring they are dressed in their own personal clothing when going out for an appointment. The DSD/designee will conduct audits that residents will go to their appointment wearing their own personal clothing/appropriate clothing by providing a visual check on a random day of the week, weekly for 1 month, then monthly for 90 days. The DSD will be notified of the scheduled appointments by reviewing residents' orders on the computer system. If the residents are not dressed appropriately during the visual check on a random day of the week/monthly, the DSD/designee will report the findings to the DON, and the DON/designee will provide an in-service to staff including certified nursing assistants and licensed vocational nurses. IV. Facility's plan to monitor corrective actions to achieve and sustain compliance; integrate the POC into the QA process: The DSD/designee will conduct audits that residents will go to their appointment wearing their own personal clothing/appropriate clothing by providing a visual check on a random day of the week, weekly for 1 month, then monthly for 90 days. The DSD will be notified of the scheduled appointments by reviewing residents' orders on the computer system. If the residents are not dressed appropriately during the visual check on a random day of the week/monthly, the DSD/designee will report the findings to the DON immediately. Thereafter, the DON/designee will provide immediate re-education through an in-service to staff including certified nursing assistants and licensed vocational nurses, and implement progressive discipline if repeated to ensure compliance. The DSD/designee will report findings from the conducted weekly/monthly audits that residents will go to their appointment wearing their own personal clothing/appropriate clothing during the monthly QAA meeting for 3 months. Compliance Date: 07/07/2025
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Dignified Medication Administration Not Maintained: A resident with severe dementia, hallucinations, anxiety, PTSD, and delusional disorder was observed during med pass in the dining room. An RN attempted to administer meds by pouring them from a plastic cup into the resident’s mouth, continued despite the resident pulling away and moving her head, and then raised her voice and questioned why the resident would not take the meds after one pill was spit out and thrown on the floor. The resident stated the nurse was not being nice, and the RN left with the refused meds.
A resident with anxiety disorder and PTSD was unable to attend meals and activities with peers because the facility lost the resident's clothing after it was sent to laundry. The resident was observed in a hospital gown with only a few clothing items in the room, and the record lacked an admission inventory of belongings. The DON/Administrator reported that laundry was handled by an outside vendor without a tracking system or item documentation.
Two residents did not receive care that maintained their dignity during grooming and personal hygiene. One resident had noticeable facial hair and reported preferring to be shaved with an electric razor, but stated that only a straight razor was available, despite facility policy and administrative statements that grooming should follow resident preference and that shaving materials are provided. Another resident was transferred to bed by a nurse and a CNA, given perineal care, and placed in a clean brief, but staff left the resident’s pants down and simply covered the resident with a blanket, contrary to administrative expectations that pants be pulled up or removed in bed according to resident preference.
A cognitively intact resident with multiple medical conditions, including chronic pain and depression, reported that while receiving a shower from a CNA, another CNA searched through the resident's purse, which had been tucked away in a nightstand, and removed Tylenol and other medications without permission. An RN documented that oxycodone from home was initially found in the purse and later placed in the medication cart, and believed the CNA had removed it from the purse without knowing if permission had been granted. The CNA stated that after a housekeeper found a pill on the floor and gave it to the CNA, a nurse instructed the CNA to search the resident's room, leading to discovery of medications in the purse on the nightstand; the CNA admitted not having permission to go through the resident's belongings. The DON was unaware of the incident but acknowledged that the CNA should not have searched the resident's belongings without consent.
A resident with a history of paranoid schizophrenia, bipolar disorder, and PTSD reported that staff conducted a random search of his room and jacket pocket without his presence or permission. A grievance documented his concern about the unaccompanied search, and the Psychosocial Rehabilitation Services Coordinator confirmed she performed the room check alone while the resident was not present. This action conflicted with the facility’s own inspection policy, which requires the resident to be present during room searches and to personally turn out their own pockets.
A cognitively intact resident with multiple medical conditions repeatedly reported that personal items such as soaps, lotions, clothing, and perfume were going missing and stated that she and her daughter had informed staff and prior administrators many times without action. CNAs acknowledged awareness of the resident’s allegations but were unsure whether these concerns had been reported, despite the DON’s stated expectation that a grievance be completed whenever items were reported missing, lost, or stolen. Only one grievance was documented, and when the findings were presented to the administrative team, they offered no comments or concerns.
Dignified Medication Administration Not Maintained
Penalty
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.
Failure to Maintain Resident Clothing and Dignity
Penalty
Summary
The facility failed to ensure a resident was treated with respect and dignity when the resident was unable to attend meals and activities with other residents because of a lack of appropriate clothing. The resident was admitted in May 2025 with diagnoses including anxiety disorder and post-traumatic stress disorder, and a care plan revised on 8/25/2025 described the resident as highly social and willing to participate in a variety of activities, with an intervention to provide reminders of scheduled events. During observation on 4/29/2026, the resident was found in the room wearing a hospital gown while other residents were in the dining room for lunch. Only one pair of pants and two T-shirts were observed in the room. The resident stated that the facility lost all of the resident's clothing, including shirts, pants, shorts, and socks, after they were sent to laundry services several months earlier and were never returned. The resident reported that the Administrator was told about the missing clothing, but no follow-up occurred and the clothing was neither located nor replaced. The record did not contain an admission inventory list of the resident's belongings, and the Administrator stated that laundry was handled by an outsourced company without a tracking system or documentation identifying which items belonged to which resident.
Failure to Maintain Resident Dignity During Grooming and Personal Care
Penalty
Summary
The facility failed to promote and maintain resident dignity for two residents who required assistance with personal hygiene and care. Facility policy on promoting/maintaining resident dignity stated that residents should be groomed and dressed according to their preferences, and the grooming policy specified assisting residents with facial hair care to maintain proper hygiene. During observation, one resident was noted to have noticeable facial hair and, in an interview, stated a preference to have facial hair shaved with an electric razor; the resident reported that the facility only had a straight razor available. An administrative staff member stated that all residents are shaved per their preferences and that shaving materials are provided, which conflicted with the resident’s report. In a separate observation, a nurse and a CNA transferred another resident from a wheelchair to a bed, completed perineal care, applied a clean brief, and then covered the resident with a blanket without pulling up the resident’s pants. Later, an administrative staff member stated that she expected staff to either pull up or remove residents’ pants in bed according to resident preference, indicating that the observed practice did not align with facility expectations or policies regarding resident dignity and grooming.
Unauthorized Search of Resident Belongings and Removal of Medications
Penalty
Summary
The deficiency involves a failure to honor a resident's right to be treated with respect and dignity and to retain and use personal possessions when a CNA searched through and removed items from a resident's purse without permission. The resident, who was cognitively intact with a BIMS score of 15/15, had diagnoses including aftercare following joint replacement surgery, hypertension, major depressive disorder, chronic pain syndrome, edema, and attention-deficit hyperactivity disorder. The resident reported that while receiving a shower from one CNA, another CNA went through the resident's purse, which had been tucked away in the nightstand, and removed Tylenol and other medications without authorization. The resident stated that the CNA had no business being in the purse and did not know if any other items were taken. Subsequent interviews and record review showed that an RN documented that oxycodone was initially found in the resident's purse and that residents could not have narcotics on their person in the building. The RN stated that the oxycodone prescription bottle from home was retrieved from the resident and placed in the medication cart and believed that the CNA had removed it from the resident's purse but did not know if the CNA had permission or where the purse was located. The CNA later stated that a housekeeper had found a pill on the floor and given it to the CNA, who then showed it to a nurse and was told to look through the resident's room to find its source; the CNA reported finding medications in the resident's purse on the nightstand and acknowledged not having permission to go through the resident's belongings. The DON was unaware of the events and acknowledged that the CNA should not have gone through the resident's belongings without permission.
Resident Rights Violated During Unaccompanied Room and Belongings Search
Penalty
Summary
The facility failed to honor a resident’s right to be treated with respect and dignity and to retain and use personal possessions when staff conducted a room search without the resident’s presence or permission. The affected resident is an adult male with a history of paranoid schizophrenia, bipolar disorder, and post‑traumatic stress disorder, admitted on June 1, 2023. On interview, the resident reported that his room was searched randomly, that he was not present, and that he had not given permission for the search; he also stated that his jacket, which was lying on his bed, had its pocket searched. A grievance form dated April 20, 2026 documented the resident’s concern about his room being searched without him present. During interview, the Psychosocial Rehabilitation Services Coordinator acknowledged that she performed a random room check of this resident’s room on April 20, 2026, did so alone, and confirmed the resident was not present during the search. The facility’s Inspection Policy states that residents must be present during room searches and that residents’ pockets may only be checked by the resident turning their own pockets inside out, which was not followed in this instance. This sequence of events, including the staff member’s admission and the documented grievance, demonstrates that the facility did not adhere to its own policy or to resident rights regarding privacy and personal possessions during the room and clothing search for this resident.
Failure to Address Resident’s Repeated Reports of Missing Personal Belongings
Penalty
Summary
Facility staff failed to honor a resident’s right to be treated with respect and dignity and to retain and use personal possessions by not appropriately addressing repeated reports of missing personal items. The resident, who had diagnoses including cancer, hypertension, and hyperlipidemia, was cognitively intact for daily decision-making as evidenced by a BIMS score of 12/15 on a recent MDS assessment. During an interview, the resident reported that personal belongings such as soaps, lotions, clothes, and a bottle of perfume (reported as broken) were being stolen on a weekly basis. The resident stated that both she and her daughter had reported these issues many times to staff, prior administrators, and nursing, but nothing had been done. The resident and her daughter again reported the missing items during a care plan meeting. Staff interviews showed that CNAs were aware of the resident’s allegations of missing items but did not consistently report them according to facility expectations. CNA #7 stated that if a resident reported missing items, they would look for the items and/or report it to the charge nurse or DON, but CNA #7 was not aware whether this resident’s missing items had actually been reported. CNA #3 recalled that the resident had previously alleged missing items but was unsure whether this had been reported to anyone. The DON stated that the expectation was that a grievance be completed whenever a resident reported missing, lost, or stolen items; however, only one grievance, dated 4/22/26, was provided, despite the resident’s reports that the problem had occurred many times. When the findings were presented to the Interim Administrator, DON, Assistant DON, and Corporate Nurse Consultant, they made no comments and voiced no concerns.
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