Finding Description
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow its policy and procedures (P&P) titled, Answering the Call Light, for six of 12 sampled residents (Residents 7, 14, 46, 59, 78, and 293) when the staff did not response to Residents 7, 14, 46, 59, 78, and 293's call lights within 5 minutes.
These failures had the potential to result in Residents 7, 14, 46, 59, 78, and 293 not attaining their needs and not maintaining their highest practicable physical, mental, emotional, and psychosocial well-being.
Findings:
During a concurrent observation and interview on 5/16/25 at 2:58 p.m. with Resident 7 in her room, Resident 7 was lying in bed, and did not respond to any questions.
During a review of Resident 7's admission Record (AR-a document containing resident profile information), dated 5/20/25, the AR indicated, Resident 7 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease (progressive brain disorder that gradually damages memory, thinking, and other cognitive functions), dysphagia (difficulty swallowing), essential hypertension (a condition where the force of blood against your artery walls is consistently too high), presence of cardiac pacemaker (a small, battery-operated device that helps regulate the heart's rhythm by providing electrical impulses when the heart's natural sinus node isn't functioning properly), all those symptoms and signs involving cognitive (the mental processes involved in knowing, learning, understanding, and thinking) functions and awareness, muscle weakness generalized, hypotension (a condition where blood pressure drops below normal levels), irritable bowel syndrome (a digestive system disorder characterized by abdominal pain and changes in bowel habits, such as diarrhea or constipation), pain, contracture(a condition where muscles, tendons, ligaments, or skin become tight and shortened, limiting the range of motion in a joint) right hand, contracture of muscle left hand, aphasia (loss of ability to understand or express speech caused by brain damage), anemia (a condition where the body has a lower than normal number of red blood cells, or the red blood cells don't function properly, leading to a reduced ability to carry oxygen).
During a review of Resident 7's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive and physical function), dated 5/15/25, the MDS section C indicated, Resident 7 had a Brief Interview for Mental Status (BIMS-assessment of cognitive status for memory and judgment) assessment score was not complete, (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment, 99 indicates unable to complete the interview).
During a review of Resident 7's MDS assessment dated [DATE], the MDS section GG indicated, Resident 7's Functional Abilities included impairment on both sides to the upper and lower extremities, Resident 7 uses wheelchair, Resident 7 is dependent (helper does all the effort, resident does none of the effort to complete self-care) on eating, oral hygiene, toileting hygiene, shower/bath self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. Resident 7 is dependent on roll left and right, sit to lying, lying to sitting on side of bed, and chair/bed to chair transfer. Sit to stand, toilet transfer and tub/shower transfer was not attempted, and Resident 7 did not perform these activity prior to the current illness .
During a review of Resident 7's MDS assessment dated [DATE], the MDS section H indicated, Resident 7's Bladder and Bowel function included Resident 7 is always incontinent (no episodes of continent voiding) for urinary continence. Resident 7 is always incontinent (no episodes of continence bowel movement) for bowel continence.
During a review of Resident 7's MDS assessment dated [DATE], the MDS section M indicated, Resident 7's Skin Conditions included Resident 7 uses pressure reducing device for chair, and pressure reducing device for bed.
During a concurrent observation and interview on 5/16/25 at 2:50 p.m. with Resident 14 in her room, Resident 14 was sitting in bed, with the head of the bed elevated . Resident 14 stated at night, the staff said it should take them 5-10 minutes to answer the call light, but it took them 30-40 minutes. Resident 14 stated it took the CNAs 4.5 hours to respond to the call light on a particular day last month. Resident 14 stated I was in my own dried stool. Why should it take that long? Resident 14 stated Resident 7 had been in her room for 2-3 years, had contracture and could no longer talk. Resident 14 stated she tried to advocate for Resident 7 and was told Resident 7 was none of her concern. Resident 14 stated I don't feel like I am treated with dignity and respect.
During a review of Resident 14's AR dated 5/20/25, the AR indicated, Resident 14, was admitted to the facility on [DATE] with diagnoses which included: partial traumatic amputation (surgical procedure involving the removal of all or part of a limb) of left shoulder and upper arm, type 2 diabetes mellitus (a chronic disease characterized by high blood sugar levels) with diabetic neuropathy (nerve damage caused by high blood sugar levels), acquired absence of right upper limb below elbow, acquired absence of right leg below knee, acquired absence of left leg below knee, pain.
During a review of Resident 14's MDS assessment dated [DATE], the MDS section C indicated, Resident 14's BIMS assessment score was 15 out of 15. BIMS scores indicated Resident 14 was cognitively intact.
During a review of Resident 14's MDS assessment dated [DATE], the MDS section GG indicated, Resident 14's Functional Abilities included impairment on both sides to the upper and lower extremities, Resident 14 uses wheelchair, Resident 14 is dependent on oral hygiene, toileting hygiene, shower/bath self, lower body dressing and personal hygiene. Resident 14 is partial/moderate assistance (helper does less than half the effort in care) on upper body dressing. Resident 14 is dependent on chair/bed to chair transfer and tub/shower transfer. Resident 14 is partial/moderate assistance on roll left and right, sit to lying, lying to sitting on side of bed.
During a review of Resident 14's MDS assessment dated [DATE], the MDS section H indicated, Resident 14's Bladder and Bowel function included Resident 14 is frequently incontinent for urinary continence. Resident 14 is frequently incontinent for bowel continence.
During a review of Resident 14's MDS assessment dated [DATE], the MDS section M indicated, Resident 14's Skin Conditions included Resident 14 uses pressure reducing device for chair, and pressure reducing device for bed.
During a review of Resident 14's MDS assessment dated [DATE], the MDS section N indicated, Resident 14's Medications included Antiplatelets (medications that work by preventing platelets from sticking together and forming clots ).
During a concurrent observation and interview on 5/13/25 at 9:37 a.m. with Resident 46 during the initial tour in Resident 46's room, Resident 46 was sitting in her wheelchair looking through some documents. Resident 46 stated I cannot walk. Resident 46 stated, the facility is short-staffed. Resident 46 stated she wheeled herself to the staff before they attend to her. Resident 46 stated it usually took about 20-30 minutes before staff responded to her call light.
During a review of Resident 46's AR dated 5/20/25, the AR indicated, Resident 46, was admitted to the facility on [DATE] from acute care hospital with diagnoses which included: heart failure, adult failure to thrive, essential hypertension, specified osteoarthritis (a degenerative joint disease where cartilage breaks down, leading to pain, stiffness, and decreased range of motion), unequal limp length acquired, pain,, history of falling, unspecified protein calorie malnutrition, muscle weakness generalized.
During a review of Resident 46's MDS assessment dated [DATE], the MDS section C indicated, Resident 46's BIMS assessment score was 14 out of 15. BIMS scores indicated Resident 46 was cognitively intact.
During a review of Resident 46's MDS assessment dated [DATE], the MDS section GG indicated, Resident 46's Functional Abilities included Resident 46 uses walker and wheelchair.
During a review of Resident 46's MDS assessment dated [DATE], the MDS section M indicated, Resident 46's Skin Conditions included Resident 46 uses pressure reducing device for chair, and pressure reducing device for bed.
During a review of Resident 46's MDS assessment dated [DATE], the MDS section N indicated, Resident 46's Medications included Diuretics (medications that help the body get rid of excess fluid and salt by increasing urine production).
During a concurrent observation and interview on 5/13/25 at 10:10 a.m. with Resident 59 during the initial tour in Resident 59's room, Resident 59 was sitting up in bed with the head of the bed elevated, with contracture of the neck to the right watching television. Resident 59 stated staff took too long to respond to the call light.
During a review of Resident 59's AR dated 5/20/25, the AR indicated, Resident 59, was admitted to the facility on [DATE] from acute care hospital with diagnoses which included: other intervertebral disc degeneration (condition where cushions between the bones of the spine break down, wear down, or dry out over time), muscle weakness generalized, chronic obstructive pulmonary disease (a progressive lung disease characterized by difficulty breathing due to persistent airflow obstruction),, primary generalized osteoarthritis , , pain, adult failure to thrive .
During a review of Resident 59's MDS assessment dated [DATE], the MDS section C indicated, Resident 59's BIMS assessment score was 15 out of 15. BIMS scores indicated Resident 59 was cognitively intact.
During a review of Resident 59's MDS assessment dated [DATE], the MDS section GG indicated, Resident 59's Functional Abilities included impairment on one side to the upper extremity, Resident 59 uses wheelchair. Resident 59 is dependent on eating, oral hygiene, toileting hygiene, shower/bath self, upper body dressing, lower body dressing, putting on/taking off footwear and personal hygiene. Resident 59 is dependent on roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, toilet transfer and tub/shower transfer .
During a review of Resident 59's MDS assessment dated [DATE], the MDS section H indicated, Resident 59's Bladder and Bowel function included Resident 59 is frequently incontinent for urinary continence. Resident 59 is frequently incontinent for bowel continence.
During a review of Resident 59's MDS assessment dated [DATE], the MDS section M indicated, Resident 59's Skin Conditions included Resident 59 has Moisture Associated Skin Damage (MASD). Resident 59 uses pressure reducing device for chair, and pressure reducing device for bed. Resident 59 gets application of ointments/ medications.
During a review of Resident 59's MDS assessment dated [DATE], the MDS section N indicated, Resident 59's Medications included Diuretics and Antiplatelets.
During a concurrent observation and interview on 5/13/25 at 12:46 p.m. with Family Member (FM) 1 in Resident 78's room, Resident 78 was lying in bed with the head of the bed elevated. FM 1 was sitting in room with Resident 78. FM 1 stated, sometimes the CNAs are standing out there doing nothing. FM 1 stated it takes about 20-30 minutes after the call light was initiated before staff respond. FM 1 stated the facility was short staffed.
During a concurrent observation and interview on 5/14/25 at 12:10 p.m. with FM 3 in Resident 78's room, Resident 78 was lying in bed with the head of the bed elevated, eating a burger. FM 3 stated resident did not get adequate supervision when eating. FM 3 stated there was no respect and dignity. FM 3 stated, while visiting Resident 78, FM 3 could hear Resident 78 yelling while coming through the facility doors. FM 3 stated Resident 78 was hungry but was ignored. FM 3 stated on another day, FM 3 saw another resident screaming she had to go to the bathroom; the resident was left alone in the hallway and nobody paid attention to the resident. FM 3 stated some of the CNAs don't like being bugged. FM 3 stated when the family members needed anything for Resident 78, FMs go out to where the staff were and let the staff know what Resident 78 needed, and it took staff about 15- 20 minutes to get resident 78 what was needed. FM 3 stated Resident 59 is Resident 78's roommate. FM 3 stated when Resident 59 uses the call light, and it takes more than 15mins for staff to respond then Resident 59 starts yelling out. FM 3 stated I sometimes go out there and tell them Resident 59 needs help.
During a review of Resident 78's AR dated 5/20/25, the AR indicated, Resident 78, was admitted to the facility on [DATE] with diagnoses which included: muscle wasting and atrophy (loss of muscle tissue and is often characterized by decreased muscle size and strength), muscle weakness generalized, unspecified abnormality of gait and mobility, type 2 diabetes mellitus, encounter for palliative care (medical consultations focused on providing comfort and support to patients with serious, life-limiting illnesses),retention of urine.
During a review of Resident 78's MDS assessment dated [DATE], the MDS section C indicated, Resident 78's BIMS assessment score was 00 out of 15. BIMS scores indicated Resident 78 had severe cognitive deficit.
During a review of Resident 78's MDS assessment dated [DATE], the MDS section GG indicated, Resident 78's Functional Abilities included Resident 78 uses wheelchair. Resident 78 is dependent on lower body dressing and putting on/taking off footwear. Resident 78 needs substantial/ maximal assistance (helper does more than half the effort) on toileting hygiene. Resident 78 needs partial/moderate assistance on oral hygiene, shower/bath self, upper body dressing, and personal hygiene. Resident 78 is dependent on sit to stand, chair/bed to chair transfer, toilet transfer and tub/shower transfer. Resident 78 needs partial/moderate assistance on roll left and right, sit to lying, and lying to sitting on side of bed.
During a review of Resident 78's MDS assessment dated [DATE], the MDS section H indicated, Resident 78's Bladder and Bowel function included Resident 78 has an indwelling urinary catheter for urinary continence. Resident 78 is always incontinent for bowel continence.
During a review of Resident 78's MDS assessment dated [DATE], the MDS section M indicated, Resident 78's Skin Conditions included Resident 78 uses pressure reducing device for chair, and pressure reducing device for bed.
During a concurrent observation and interview on 5/13/25 at 3:15 p.m. with Resident 293 during the initial tour in Resident 293's room, Resident 293 was lying in bed. Resident 293 stated it takes staff too long to answer the call light. Resident 293 stated it took about 20 -30 minutes for staff to respond. Resident 293 stated this can be frustrating because when I need help, I don't get it on time.
During a review of Resident 293's AR dated 5/20/25, the AR indicated, Resident 293 was admitted to the facility on [DATE] with diagnoses which included: disorder of the autonomic nervous system (a condition where the nerves that regulate involuntary bodily functions (like heart rate, blood pressure, digestion) are not functioning correctly), difficulty in walking, muscle weakness generalized, pain due to vascular prosthetic devices implants and grafts (man-made materials used to replace or repair damaged blood vessels), immunodeficiency (a condition where the immune system is unable to effectively fight off infections and diseases), type 2 diabetes mellitus, anemia, unspecified mood affective disorder (mental health conditions characterized by persistent or severe disturbances in mood and emotions), unspecified hearing loss bilateral (hearing loss affecting both ears), essential hypertension, hypertensive heart disease, chronic ischemic heart disease (a condition where the heart muscle receives less oxygen-rich blood due to narrowed or blocked coronary arteries), foot drop right foot, injury of sciatic nerve at hip and thigh level right leg (results in range of symptoms, including pain, numbness, weakness, and difficulty with movement and sensation in the leg and foot) .
During a review of Resident 293's MDS assessment dated [DATE], the MDS section C indicated, Resident 293's BIMS assessment score was 12 out of 15. BIMS scores indicated Resident 293 has moderate cognitive deficit.
During a review of Resident 293's MDS assessment dated [DATE], the MDS section GG indicated, Resident 293's Functional Abilities included impairment on one side to the lower extremity, Resident 293 uses wheelchair. Resident 293 needs substantial/ maximal assistance on toileting hygiene, shower/bath self, lower body dressing, and putting on/taking off footwear. Resident 293 is partial/moderate assistance on personal hygiene. Resident 293 is partial/moderate assistance on roll left and right, sit to lying, lying to sitting on side of bed, sit to stand, chair/bed to chair transfer, toilet transfer and tub/shower transfer. Resident 293 is partial/moderate assistance on picking up objects.
During a review of Resident 293's MDS assessment dated [DATE], the MDS section H indicated, Resident 293's Bladder and Bowel function included Resident 293 is occasionally incontinent for urinary continence.
During a review of Resident 293's MDS assessment dated [DATE], the MDS section M indicated, Resident 293's Skin Conditions included Resident 293 has Moisture Associated Skin Damage (MASD). Resident 293 uses pressure reducing device for chair, and pressure reducing device for bed. Resident 293 gets application of ointments/ medications.
During a review of Resident 293's MDS assessment dated [DATE], the MDS section N indicated, Resident 293's Medications included Anticoagulant (medications that prevent or reduce blood clot formation), Antiplatelets and Hypoglycemic (drugs used to lower blood sugar levels).
During a review of the facility's Resident Council Minutes, dated 1/30/25, the document indicated .Review of past month's issues: .Call lights still take too long to respond .floor staff having attitude when responding to call lights. Concerns: Call lights have not improved on all shifts, still having to wait 30 minutes to be assisted with and CNA are still not assisting residents that are not assigned to that CNA. Call light takes too long to respond Call light is being ignored, and CNA will walk past light and yell back that they will be right back .
During a review of the facility's Resident Council Minutes, dated 2/26/25, the document indicated .Concerns: Call lights still take too long to respond CNA limit time assisting with residents so they can get to the next resident. {Unnamed} resident states he/she doesn't get clean .Call lights still waiting 30 to 35 minutes to get assisted. Would like floor staff to acknowledge call lights .
During a review of the facility's Resident Council Minutes, dated 3/27/25, the document indicated .Concerns: NOC (Night Shift) CNA are responding to call light with attitude when responding to a 30-to-40-minute wait on call light. CNA tells resident to quit messing with the call light . Residents wants more help and staff on floor at PM and NOC shifts to help with call lights .
During a review of the facility's Resident Council Minutes, dated 4/25/25, the document indicated .Concerns: CNA at NOC/PM shift takes too long to respond. One night [resident] had to wait 4 hours for a CNA to respond to call light. CNA stated she was busy. CNAs still has attitude when responding to call light. There is no improvement on call lights Residents would like floor staff to be retrained (for the new hires). Residents feel that new floor staff don't know what they are doing. New CNA on the floor needs more training on how to assist a patient and to know how to change patients Wait 30 minutes on call light on PM shift from 3p.m. to 11p.m Call light takes too long to respond to .
During the assigned facility task Resident Council dated 5/15/25 at 10:03 a.m. in the facility's dining room, there were concerns of staff not responding to the call light in a timely manner. Resident 14 stated there was no dignity and respect all the time. Resident 14 stated CNAs, especially the new CNAs, have attitude. Resident 14 stated she was given attitude when she told the CNAs regarding Resident 7's care because Resident 7 is unable to talk. Resident 14 stated the facility tells her complaints will be addressed, but complaints are not addressed. Resident 14 stated They always tell me; everything will be alright. It makes me feel like I am nothing. Resident 14 stated it shouldn't take 30-40 minutes to answer the call light. Resident 14 stated this happens on a regular basis, on the PM and NOC shift. Resident 14 stated she had used the bathroom and had dried stool all up her back and it took a CNA 4.5 hours to respond to her call light. Resident 14 stated she addressed it with the LNs, DSD and DON. Resident 14 stated DSD and DON took a report and there was no feedback. Resident 14 stated I am concerned about the call lights.
During an interview on 5/20/25 at 1:39 p.m. with Licensed Vocational Nurse (LVN) 7, LVN 7 stated the call light policy states call lights should be answered within 15 mins .
During an interview on 5/20/25 at 1:43 p.m. with Certified Nursing Assistant (CNA) 5, CNA 5 stated sometimes there were not enough CNAs on PM shifts. CNA 5 stated, sometimes CNAs were unable to get to all the residents.
During a concurrent interview and record review on 5/20/25 at 1 :37p.m. with the Director of Staff Development (DSD), the call light policy was reviewed. The DSD stated the expectation was for CNAs to check residents who were unable to call for assistance every 2 hours or as needed. The DSD stated the expectation from staff was that the call lights should be answered within 7 minutes. The DSD stated the expectations were not met. The DSD stated the P&P indicated .Answer immediately, .within 5 minutes. The DSD stated the policy was not followed.
During a concurrent interview and record review on 5/20/25 at 3:11 p.m. with the Director of Staff Development (DSD), the resident council minutes for the months of January 2025 - April 2025 were reviewed. The DSD validated there were lots of complaints about call lights from the resident council minutes. The DSD stated the minutes indicated call lights were not answered timely. The DSD confirmed been aware of the complaints. The DSD stated the complaints were not properly addressed by the facility; therefore, residents continue to complain.
During a concurrent interview and record review on 5/20/25 at 3 :02 p.m. with the Director of Nursing (DON), the call light policy was reviewed. The DON stated the expectation were when residents turn on their call light, staff should respond and assess the needs of the residents and if unable to meet the needs, staff should refer to another department or discipline if needed. The DON stated staff should answer call light in a timely manner as soon as practically possible. The DON stated the policy was not followed. The DON stated it was important to follow the policy, so the patient gets timely responses to their needs.
During a concurrent interview and record review on 5/20/25 at 3:28 p.m. with the Director of Nursing (DON), the resident council minutes for the months of January 2025 - April 2025 were reviewed. The DON stated a 4.5-hour response to the call light was not appropriate. The DON stated potential outcome of not responding to the call light would be that the residents' needs would not be acknowledged. The DON stated she was not aware of the incident of resident in own stool unattended to after initiating call light for 4.5 hours. The DON stated that a resident left unattended in own stool for 4.5 hours was not fair and was not right.
During a concurrent interview and record review on 5/20/25 at 3:28 p.m. with the Administrator (ADM), the call light policy and the resident council minutes for the months of January 2025 - April 2025 were reviewed. The ADM stated the resident council minutes were reviewed with the activity's director after the resident council meetings. The ADM stated if there were issues in any department, something should be done about it. The ADM stated he was aware of the call light complaints. The ADM stated staff needed to be educated more on proper call light response time with more of a focus on the afternoon shift night shift. The ADM stated the call light policy was not followed.
During a review of the facility's document titled, Job Description, Certified nursing assistant (CNA), dated 2/2024, the document indicated, . General purpose . to provide each of your assigned residents with routine daily nursing care and services in accordance with the resident's assessment and care plan . Essential Duties . create and maintain an atmosphere of warmth, personal interest and positive emphasis as well as a calm environment throughout the unit and shift, . ensure that residents who are unable to call for help are checked frequently, answer resident calls promptly, check residents routinely to ensure that their personal care needs are met, . cooperate with . other facility personnel to ensure that nursing services can be adequately maintained to meet the needs of the residents, . assist residents with daily functions (dental and mouth care, bath functions, combing of hair, dressing and undressing as necessary), keep residents dry (change gown, clothing and linens, when it becomes wet or soiled), check each resident routinely to ensure that his/her personal care needs are being met in accordance with his/her wishes .
During a review of the facility's document titled, Job Description, LPN/LVN, dated 2/2024, the document indicated, . Directs the day-to-day functions of the nursing assistants in accordance with current rules regulations and guidelines ., ensure all nursing personnel assigned to you comply with written policies and procedures ., make daily rounds of your unit/ shift to ensure that nursing service personnel are performing their work assignments in accordance with acceptable nursing standards . ensure that personnel providing direct care to residents are providing such care in accordance with the resident care plans and wishes, ensure that residents who are unable to call for help are checked frequently . ensure that your assigned certified nursing assistants (CNAs) are aware of the residents care plan .
During a review of the facility's document titled, Job Description, Registered Nurse (RN), dated 2/2024, the document indicated, . Ensure that all nursing service personnels are in compliance with their respective job descriptions ., ensure that a sufficient number of licensed practical and/ or registered nurses are available for your tour of duty to ensure that quality care is maintained, ensure that a sufficient number of certified nursing assistants are available for your tour of duty to ensure that routine nursing care is provided to meet the daily nursing care needs of each resident, . make daily rounds of nursing service department to ensure that all nursing service personnel are performing their work assignments in accordance with acceptable nursing standards, . visit residents on a daily basis in order to observe and evaluate each resident's physical and emotional status, . ensure that residents who are unable to call for help are checked frequently .
During a review of Job Description: Director of Staff Development (DSD), dated 2/2024, the document indicated, .General Purpose . is responsible to plan and implement facility orientation, job skill training . for the nursing assistants as required by regulation. Work with the Director of Nursing and Administrator to ensure that the highest degree of quality care is maintained at all times . Essential Duties . plan and conduct meaningful in-service education programs according to requirements for nursing personnel and all facility staff to assure competency in and new skills and as directed by administrator. Make rounds and observe delivery of patient care .
During a review of Job Description: Director of Nursing (DON), dated 2/2024, the document indicated, .General Purpose . oversees and supervises the care of all residents . Essential Duties . Develop and implement nursing policies and procedures and ensure compliance. Responsible for ensuring resident safety and that all residents are treated with utmost respect Work closely with all other departments to ensure excellent overall resident care . coordinate MDS and care planning .
During a review of the facility's policy and procedure titled, Answering the Call Light, dated 09/2022, indicated, .Policy Statement- The purpose of this procedure is to ensure timely responses to the resident's requests and needs . Steps in the procedure 1. Answer the resident call system immediately .a. If the resident needs assistance, indicate the approximate time it will take for you to respond. b. if the resident's request requires another staff member, notify the individual. c. if the resident's request is something you can fulfill, complete the task within five minutes if possible. d. If you are uncertain as to whether or not a request can be fulfilled, or if you cannot fulfill the resident's request, ask the nurse supervisor for assistance.2. if assistance is needed when you enter the room, summon help by using the call signal .
During a review of the facility's policy and procedure titled, Resident Rights, dated 2/2021, indicated, .Policy Statement- Employees shall treat all residents with kindness, respect, and dignity. Policy Interpretation and Implementation: 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's rights to: a. a dignified existence. b. be treated with respect, kindness and dignity. c. be free from abuse neglect misappropriation of property and exploitation . u. Voice grievances to the facility or other agency that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. v. Have the facility[TRUNCATED]