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F0550
D

Failure to Honor Resident's Dignity and Preferences for Staff Conduct

Denver, Colorado Survey Completed on 12-04-2025

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

A deficiency occurred when staff failed to honor a resident's right to dignity and respect by not adhering to her expressed preferences regarding staff conduct upon entering her room. The resident, who was under 65 years old with diagnoses including bipolar disorder, chronic respiratory failure, and type 2 diabetes mellitus, was cognitively intact and dependent on staff for activities of daily living. Despite clear handwritten signs on her door requesting that staff knock, announce themselves, and wear a face mask before entering (with masks readily available in her room), staff members were observed entering without knocking or wearing a mask. The resident reported feeling horrible and disrespected when staff entered without following her preferences, which were not documented in her care plan. Interviews with staff and the nursing home administrator confirmed that the resident's wishes were known but not consistently communicated or implemented in the care plan. The administrator acknowledged that staff should have knocked and worn masks as requested, and that these preferences should have been included in the resident's care plan to ensure consistent care.

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