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.
An RN fed a resident fortified pudding in a common TV area while other residents were present and remained standing instead of sitting at eye level during the feeding. The RN acknowledged she forgot to sit, and the ADON confirmed staff were expected to sit while feeding residents to promote dignity during meals. The resident had dementia and a BIMS score of 4, indicating severely impaired cognition.
A resident’s room had a posted sign instructing staff to apply compression hose daily and remove them at bedtime. The resident, who was cognitively intact and had edema and a history of venous thrombosis and embolism, stated her legs were swollen and she did not yet have the hose on. An LPN confirmed the sign was meant to remind CNAs, while the DON stated the signage was a dignity issue and should not have been on the wall.
A resident with a history of leg amputation and Type 2 DM, who was cognitively intact, was propelling in a wheelchair down a hallway and slowed near a beauty shop doorway where a CNA was standing. Video showed the CNA striking the brim of the resident’s cap with light to moderate force, pushing the resident’s head downward while both of the resident’s hands remained on the wheelchair wheels. Only after the cap was struck did the resident remove a hand and elbow the CNA in the thigh/hip area. The CNA later claimed the resident had touched her buttocks and grabbed her clothing and said she tapped his cap to make him let go, despite video evidence to the contrary, and acknowledged she had prior in-servicing on abuse, neglect, resident rights, and dementia care. The resident reported that the CNA frequently engaged in similar behavior that he did not like, stated he should be treated right, and felt the CNA did not treat him with respect, while facility leadership acknowledged that the CNA initiated the altercation and failed to honor the resident’s right to dignity and respect.
A cognitively intact, fully dependent resident with a right BKA and multiple rib fractures remained in a soiled brief and heavily soiled bed linens for an extended period after a bowel movement, despite pressing the call light and being briefly checked by staff who did not return. The resident expressed embarrassment, humiliation, and a desire to leave, and his representative reported finding him "in a mess," notifying staff at the nursing desk, and observing a nurse enter and then leave the room without care being provided. Later, the ADM and DON observed the resident still lying in feces-soiled linens and acknowledged that he relied on staff for all ADLs and that his condition was unacceptable and a dignity issue.
A resident’s urinary catheter drainage bag was observed hanging visibly on the side of the bed without a privacy bag, and the QA Nurse confirmed it was exposed and a dignity concern. The resident had multiple medical diagnoses, including a stage 4 sacral pressure ulcer, HF, COPD, and CKD, and had moderate cognitive impairment per BIMS.
Failure to honor a resident's right to refuse fingerstick blood glucose checks and use a CGM for monitoring. A resident with Type 2 DM and moderately impaired cognition repeatedly stated that fingersticks hurt and that he did not like them, while his daughter and RR reported staff kept doing fingersticks even after providing the CGM and posting signage. An LPN continued the fingerstick despite the resident's refusal, and the DON confirmed the facility had agreed to use the CGM if supplies were provided.
Two cognitively intact residents experienced undignified care when staff failed to provide timely toileting assistance and used disrespectful communication. One resident, with multiple chronic conditions, reported that a CNA questioned her need to use the bathroom at night and later left her sitting on the toilet for about 30 minutes until she used the bathroom call light, after which the CNA stated she had to make her rounds. Another resident with cerebral palsy, incontinent and fully dependent on staff for toileting and hygiene, was found by a family member with the call light sounding, wet, and with three soiled, spaghetti-covered towels left on her chest from lunch; when a CNA entered, she removed the towels and told the resident she was "just showing out" because her sister was present. The DON and nursing staff interviews confirmed expectations that residents be treated with dignity and respect and receive timely toileting.
A cognitively intact resident with a history of major depressive disorder was denied her right to receive visitors of her choosing when her regular visitor and friend was told by staff to leave the facility and was not allowed to stay or have the resident notified of his presence. The facility’s own Resident Rights policy states that residents may receive visitors of their choosing at times of their choosing, yet the IDON acknowledged she directed the friend to leave and confirmed staff did not inform the resident of the attempted visit, while the Administrator later stated he was unaware of the incident.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Get More From Your Search Results
Create an account to access advanced search filters, save your searches, and get unlimited access to detailed Plan of Corrections.
Create an Account