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F0550
D

Failure to Knock Before Entering Resident Room Violates Dignity and Privacy

Victoria, Texas Survey Completed on 11-26-2025

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

Staff failed to treat a resident with respect and dignity by not knocking before entering her room on multiple occasions. Observations showed that both the MDS nurse and a speech therapist entered the resident's room without knocking, despite the resident being present and her call light being on. Interviews with the staff involved confirmed that they were trained on resident rights and facility policy, which requires staff to knock and announce themselves before entering any resident's room. Both staff members acknowledged that not knocking was disrespectful and intrusive, and that all residents should receive the same respect. The resident, who has a history of muscle weakness, difficulty walking, cognitive communication deficit, insomnia, major depressive disorder, and hypertensive emergency, reported that staff frequently entered her room without knocking, which upset her and made her feel her privacy was invaded. Facility leadership, including the DON and administrator, confirmed that the policy requires staff to knock and that monitoring is done through observations and rounds. The facility's resident rights policy emphasizes respect for personal privacy and dignity, but the failure of staff to follow this policy led to the deficiency.

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