The resident threw off the blanket during the meal, exposing herself to other patients and staff. Multiple employees witnessed the incident but disagreed about whether it violated the woman's dignity.
Staff A, a certified nursing assistant who also serves as activity director, told inspectors on August 27 that she observed staff bring Resident #4 to the dining room "in a nightgown with a lap blanket covering her legs." She called it "a dignity issue."
The MDS Coordinator saw the same incident. "She observed Resident #4 in the dining room with a shirt and a brief on and a blanket covering her," inspectors wrote. "She stated the resident threw the blanket off and she thought she should have pants on."
But the Director of Nursing claimed ignorance. She told inspectors that "staff should not bring residents to the dining room without pants and she was not aware that happened."
The resident's medical records show extensive cognitive and physical impairments. Her July assessment listed non-Alzheimer's dementia, anxiety disorder, and diabetes. She scored 9 out of 15 on a mental status exam, indicating moderately impaired cognition. Staff must provide extensive assistance with all activities of daily living, including lower body dressing and toileting hygiene.
The facility's own policy requires maintaining respect for residents.
Staff also violated dignity standards by putting multiple incontinence products on the woman simultaneously. Licensed Practical Nurse Staff B told inspectors "she was aware that staff applied more than one incontinent product to Resident #4 such as a pull-up with a pad in it."
She said she told staff this practice was inappropriate. They did it "because she soaked through," Staff B explained to inspectors. Instead of layering products, "staff needed to change the resident more often."
The LPN said she last witnessed the double-product practice "a couple of weeks ago."
The MDS Coordinator confirmed seeing "residents with double incontinent products on." She believed staff used this method because residents were "heavy wetters" and "for convenience."
Multiple staff members knew about both dignity violations but responses varied widely. Staff B said she educated the nursing assistant about bringing residents to meals improperly dressed. But the Director of Nursing insisted she was unaware of the dining room incident.
The facility operates with just 19 residents, making oversight of individual cases more manageable than in larger nursing homes. Yet multiple staff witnessed dignity violations without consistent intervention.
Federal inspectors found these violations during a complaint investigation on August 28. The inspection focused specifically on dignity issues after receiving reports about inappropriate treatment of residents.
The woman's care plan, most recently revised in April 2024, documents her need for extensive assistance with dressing. An earlier entry from August 2023 noted she required extensive help with all activities of daily living.
Her cognitive impairment scores indicate she cannot advocate for herself or understand when her dignity is compromised. The Brief Interview for Mental Status assessment measures orientation, memory, and attention. Scores below 13 indicate cognitive impairment that affects decision-making ability.
Staff responses revealed inconsistent training and supervision. While some employees recognized dignity violations and attempted education, others remained unaware of incidents affecting vulnerable residents under their care.
The double incontinence product practice reflects broader staffing challenges. Rather than providing more frequent changes as medically appropriate, staff chose convenience methods that potentially caused discomfort and skin problems for residents.
Federal regulations require nursing homes to help residents maintain dignity in all aspects of care, including dressing, toileting, and dining experiences. The violations at MercyOne Centerville demonstrate how cognitive impairment makes residents particularly vulnerable to dignity breaches.
The facility received a "minimal harm" citation affecting few residents, but the findings illustrate systemic supervision problems. When multiple staff witness inappropriate care without consistent response, vulnerable residents remain at risk for repeated dignity violations.
The woman with dementia continues living at the facility, dependent on the same staff who failed to maintain her dignity during routine care activities.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mercyone Centerville Medical Center from 2025-08-28 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Mercyone Centerville Medical Center
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