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F0550
D

Failure to Honor Resident's Mask Preference and Right to Self-Determination

Madison, Wisconsin Survey Completed on 12-15-2025

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 honor a resident's expressed preference for staff to wear masks when entering his room. Despite clear signage on the resident's door and a dry erase board indicating this preference, surveyors observed multiple staff members, including certified nursing assistants, entering the resident's room without wearing masks and without asking the resident if it was acceptable to do so. Interviews with staff revealed that they did not consistently follow the resident's request, with one CNA stating that staff typically entered without masks and believed it did not bother the resident. However, when interviewed, the resident confirmed that it was his preference for staff to wear masks and that it did upset him when they did not comply. The resident involved had diagnoses including pneumonitis due to inhalation of food and vomit, and chronic kidney disease stage 3, and was assessed as cognitively intact. The facility's own Resident Rights admission document affirms the right to a dignified existence, self-determination, and reasonable accommodation of resident needs and preferences. Despite this, the resident's preference regarding mask use was not incorporated into his care plan, and staff did not consistently respect or accommodate his wishes, resulting in a failure to uphold his rights as outlined by facility policy.

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