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F0557
D

Failure to Treat Resident with Dignity and Respect

Springfield, Missouri Survey Completed on 11-29-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that all residents were treated with dignity and respect, specifically in the case of one resident who was dependent on staff for transfers, bed mobility, and toileting. The resident, who had diagnoses including diabetes, heart failure, severe obesity, anxiety disorder, and depression, expressed a preference to wear an incontinent brief to bed and to have his or her sleeping patterns honored, as documented in the care plan. However, Certified Nurse Aide (CNA) A repeatedly spoke to the resident in a disrespectful manner, making comments about back pain caused by assisting the resident and expressing reluctance to help. CNA A also slammed the door when leaving the resident's room, which the resident found hurtful and disrespectful. Multiple interviews with other staff members confirmed that CNA A discouraged the resident from wearing an incontinent brief to bed, insisting it was healthier to sleep without one, despite the resident's stated preference. The resident reported feeling pressured by CNA A to comply with this suggestion, ultimately relenting to avoid conflict, even though it made the resident feel uncared for and diminished. Other CNAs and LPNs corroborated that CNA A's behavior was perceived as disrespectful and that the resident had shared concerns about not receiving timely incontinent care during the night shift. The facility's policy required staff to respect residents' autonomy, dignity, and preferences, including sleeping routines and personal care choices. Despite this, CNA A's actions and comments did not align with these expectations, as evidenced by the resident's repeated experiences of disrespect and disregard for personal preferences. The issue was further compounded by the resident's reluctance to report the behavior due to fear of retaliation and a desire to avoid causing trouble for staff.

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