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F0558
D

Failure to Honor Resident's Right to Make Choices Regarding Room Temperature and Care

Pembroke, North Carolina Survey Completed on 11-21-2025

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 a nurse aide (NA) turned off a resident's air conditioning against the resident's explicit wishes, thereby failing to honor the resident's right to make choices. The resident, who had a history of hemiplegia, cerebral infarction, and anxiety disorder, was cognitively intact and dependent on staff for transfers and toileting hygiene. On the night of the incident, the resident requested assistance with incontinence care and to be helped to bed. When the two NAs entered the room, they asked if they could turn off the air conditioner due to the cold temperature, but the resident refused. Despite this, one NA turned off the air conditioner, prompting the resident to use a curse word in protest. Following the resident's response, both NAs refused to provide the requested care and left the room, stating they did not want to argue with the resident. The incident was witnessed by the resident's roommate, who confirmed that the NAs disregarded the resident's wishes and left after being spoken to disrespectfully. The NAs later reported the incident to the nurse on duty. Both NAs stated they had received training on resident rights, including the right to make personal choices. Interviews with facility leadership, including the DON and the Administrator, confirmed that the NAs should not have turned off the air conditioner without the resident's permission and should have provided care regardless of the resident's language. The staff's actions resulted in the resident's choices not being respected and necessary care being withheld.

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