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F0550
D

Failure to Maintain Resident Dignity During Public Argument

Windsor, North Carolina Survey Completed on 11-14-2025

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 honor residents' rights to a dignified existence and self-determination, as evidenced by an incident involving a loud and public argument between the Administrator and a cognitively intact resident. The confrontation began when the resident requested to speak with the Administrator regarding nursing care and became verbally aggressive. The Administrator responded in a similarly elevated tone, and the argument escalated in the hallway, drawing the attention of multiple staff members and other residents. The situation was not deescalated by staff, and the exchange continued in a manner that was loud and disruptive. Several staff members, including the ADON, Nurse Aide, Activities Director, Rehabilitation Program Manager, PT Assistant, and DON, witnessed the event. Staff interviews confirmed that the argument was conducted in a public area, within hearing distance of other residents, and that the Administrator and the resident were both raising their voices. The ADON instructed a nurse aide to call the police, and the PT Assistant eventually led the Administrator outside to separate her from the situation. Law enforcement was called and spoke with the resident following the incident. Another cognitively intact resident, who was in the hair salon nearby, reported hearing the entire exchange and described the behavior of both the Administrator and the resident as undignified and unprofessional. Multiple staff corroborated that the argument was loud, public, and not appropriate for the setting. The incident demonstrated a failure to maintain resident dignity and to manage conflict in a manner that respected the rights and privacy of those involved and those who witnessed the event.

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