§483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.
§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.
§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.
§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.
§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.
§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
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Observations:
Based on clinical record review, observation, resident interview, and staff interview, it was determined that the facility failed to provide care and services to maintain dignity and preferences to promote quality of life for two of ten sampled residents. (Residents 1 and 10)
Findings include:
Clinical record review revealed that Resident 1 had diagnoses that included Parkinson's disease, muscle weakness, and dementia. Review of the Minimum Data Set (MDS) assessment dated March 3, 2026, revealed that Resident 1 required assistance with activities of daily living and had moderate cognitive impairment. Review of the care plan dated July 15, 2025, revealed that staff were to assist the resident with transfers, movement and dressing. On June 4, 2026, at 10:15 a.m., Resident 1 was observed in bed wearing his night clothes. At 10:30 a.m., and 10:44 a.m., the call bell for Resident 1's room was observed to be activated. At 11:00 a.m., Resident 1 was observed in bed. He remained in his night clothes. He stated that he had asked the nurse who responded to his call bell both times to assist him with dressing for the day. The nurse had left without providing or offering assistance. At 11:28 a.m., Resident 1 was observed in bed, still in his night clothes. Resident 1 stated that he preferred to get out of bed before 9:00 a.m.
Clinical record review revealed that Resident 10 had diagnoses that included hemiplegia and hemiparesis (paralysis) due to a stroke, and a seizure disorder. Review of the MDS assessment dated May 7, 2026, revealed that Resident 10 required assistance with activities of daily living and did not have cognitive impairment. Review of the care plan dated February 13, 2026, revealed that staff were to assist the resident with transfers, movement and dressing. On June 4, 2026, at 10:41 a.m., the call bell for Resident 10's room was observed to be activated. At 10:44 a.m., Resident 10 stated that she was waiting for an aide to assist her with dressing. She stated that she preferred to be out of bed before 9:00 a.m.; that she had pressed the call bell twice since 8 a.m.; and that staff had turned it off without offering assistance. At 11:25 a.m., Resident 10 was observed in bed, still in her night clothes. In an interview at 1:25 p.m., Resident 10 stated that she was not assisted to dress until 12:28 p.m.
In an interview on June 4, 2026, at 4:24 p.m., the Director of Nursing confirmed that Residents 1 and 10 had not been provided timely assistance to maintain their dignity and respect their preferences.
28 PA Code 211.12(d)(1)(5) Nursing services.
| | Plan of Correction - To be completed: 07/16/2026
All residents have the potential to be affected by this deficient practice.
R1 and R10 nurse and cna were educated by staff development coordinator on performing care as per resident preference/request on this date. R1 and R10 preference to get out of bed was added to their plan of care. An audit will be completed with all residents who can make needs known to ensure preferences to get out of bed are part of their plan of care. Staff will be educated on preferences by Don or designee.
All staff will be educated by staff development coordinator on providing care and services to maintain dignity and preferences of residents.
Don or designee will complete random audits to ensure residents who have preferences for getting out of bed are met. weekly audits 4 then monthly x2
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