Failure to Ensure Cognitive Ability Before Signing Arbitration Agreements
Summary
The facility failed to ensure that residents had the cognitive ability to understand and sign binding arbitration agreements. This deficiency was identified for four residents who were assessed to have severely impaired cognition, as indicated by their Brief Interview for Mental Status (BIMS) scores. Resident 71 had a BIMS score of six, while Residents 84, 75, and 44 each had a BIMS score of one, all indicating severe cognitive impairment. Despite this, these residents signed arbitration agreements without the necessary cognitive capacity to understand the terms. In the case of Resident 71, the resident's niece was present during the signing but did not have power of attorney. The niece understood the agreement but chose not to sign it herself, allowing the resident to sign instead. For Resident 84, the Admissions Coordinator communicated with the resident's grandson over the phone, who explained the agreement in Spanish to the resident. However, the Admissions Coordinator could not verify the resident's understanding due to the language barrier. Resident 75's daughter, who did not have power of attorney, explained the agreement to her mother in Spanish and permitted her to sign it. Resident 44, who had no legal representative or family, signed the agreement after a friend, contacted by phone, gave verbal consent. Interviews with the Admissions Director and Admissions Coordinator confirmed that these residents lacked the cognitive ability to comprehend the agreements they signed. The facility's Administrator acknowledged that it was unacceptable for residents to sign arbitration agreements without understanding them and stated that such instances should be considered refusals if the resident or their representative did not wish to sign.
Plan Of Correction
1/7/25 The [R] Agreements for R71, R84, R75 and R44 were rescinded. A facility wide audit was completed on all signed [R] Agreements in comparison to Brief Interview for Mental Status (BIMS) Assessment score and were corrected. All residents have the potential to be affected by this deficient practice. The Administrator inserviced the Admissions Department on the proper procedure for conducting Arbitration Agreements in accordance to their Brief Interview for Mental Status (BIMS) Assessment score. The Minimum Data Set (MDS) Coordinator will audit 3 new admissions per month for accurate Arbitration Agreements signature in accordance to Brief Interview for Mental Status (BIMS) Assessment score. The Minimum Data Set (MDS) Coordinator will report the results of these audits to the Administrator on a monthly basis. The Minimum Data Set (MDS) Coordinator will review the findings of the monthly audits at the Quarterly QAPI Meeting for the next 2 quarters.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with documented capacity to make decisions signed an arbitration agreement, but staff did not ensure it was explained in a way he understood. During interviews, the resident showed confusion about the process, stated he did not understand the agreement, and said he signed it because staff wanted him to. The AA said she explains arbitration in person if a resident is alert, while the SSD and RN noted periods of confusion and the resident made statements suggesting impaired understanding.
A facility arbitration agreement incorrectly stated that it could not be rescinded within 30 days of signature, and this version was used for three residents. The residents had psychiatric diagnoses and varying documentation of capacity/cognition, and the SSD confirmed the same erroneous agreement had been signed over the past 3 years. The ADM stated the error had the potential to violate resident rights by not providing the 30-day rescission period.
A resident with dementia, moderate cognitive impairment on BIMS, and a documented POA signed admission paperwork that included a binding arbitration agreement. The record described the resident as confused, a poor historian, and unable to care for himself, while staff noted family concerns about the POA and did not document attempts to contact the POA. The NHA later confirmed the facility failed to ensure the resident had the capacity to understand the arbitration agreement.
A resident with severely impaired cognition and documented lack of decision-making capacity had a binding arbitration agreement signed in the resident’s name. The AD and AA stated the agreement was explained and the resident nodded, but they did not verify capacity or confirm informed decision-making with nursing staff, and the facility policy required verbal acknowledgment from the resident or representative before signing.
Arbitration Agreement Missing Required Resident Rights Language: A resident with multiple diagnoses, including dementia, COPD, and dysphagia, had an arbitration agreement that did not state that signing was not a condition of admission or continued care, and did not state that the resident could communicate with federal, state, or local officials, including surveyors and the State Long Term Care Ombudsman. The AD confirmed the omissions after the agreement was reviewed during the survey process.
Arbitration Agreement Missing Required Communication Language: The facility’s arbitration agreement for three residents did not include required language stating that the resident or a representative could communicate with federal, state, or local officials, including surveyors and the Ombudsman. One resident had impaired cognition and could not make medical decisions, while the other two had capacity and intact cognition. The AC and ADM acknowledged the language was missing from the agreement, and the facility policy stated the agreement may not prohibit or discourage these communications.
Arbitration Agreement Not Explained in Understandable Manner
Penalty
Summary
The facility failed to ensure the Binding Arbitration Agreement was explained in a manner understandable to Resident 183, despite documentation indicating the resident had the capacity to understand and make decisions. Resident 183’s Face Sheet showed admission from a hospital with diagnoses including osteoporosis, and the MDS described him as moderately cognitively impaired but still able to make daily decisions. The resident signed the arbitration agreement on 4/22/2026, and the H&P dated 4/23/2026 stated he had the capacity to understand and make decisions. During interviews on 4/23/2026, Resident 183 did not recall signing the agreement and gave responses showing limited understanding of the arbitration process, including asking who would be his arbitrator and stating, “Vaguely. My brain is slowly growing back.” The SSD and RN reported periods of confusion, and the AA stated she explains the arbitration process in person if a resident is alert. When asked if he understood the agreement, Resident 183 stated, “No. I just signed it because they wanted me to.” The AA, DON, and ADON were present during the discussion, and the facility’s Question/Answer Arbitration Agreement document described arbitration as a private way to resolve disputes rather than going to court.
Arbitration Agreement Misstated Residents’ 30-Day Right to Rescind
Penalty
Summary
The facility failed to ensure its arbitration agreement accurately reflected residents’ right to rescind the agreement within 30 days for three sampled residents. The facility’s undated Resident-Facility Arbitration Agreement stated, “This agreement may not be rescinded by written notice within thirty (30) days of signature,” which conflicted with the residents’ right to refuse or withdraw from the agreement. During interview, the Social Services Director stated this typographical error had been in the agreement used for the last 3 years and that the agreements containing the error were signed by Resident 15, Resident 26, and Resident 41. Resident 15 had diagnoses including schizoaffective disorder bipolar type, DM, and COPD, with documentation showing fluctuating capacity in the H&P and intact cognition on the MDS. Resident 26 had diagnoses including bipolar disorder, schizophrenia, and suicidal ideations, with intact cognition on the MDS and capacity to understand and make decisions documented in the H&P. Resident 41 had diagnoses including schizophrenia, anxiety disorder, and depression, with fluctuating capacity in the H&P and intact cognition on the MDS. The Administrator stated the typographical error had the potential to violate resident rights by not providing the 30-day time period to rescind the agreement.
Failure to Verify Capacity Before Signing Arbitration Agreement
Penalty
Summary
The facility failed to ensure that a resident had the capacity to understand the terms of a binding arbitration agreement before signing admission paperwork. Resident R64 was admitted with diagnoses including high blood pressure, hyperlipidemia, and dementia, and the admission MDS dated 8/17/25 showed a BIMS score of 11, indicating moderate cognitive impairment. Pre-admission hospital records described the resident as a poor historian with cognitive impairment/dementia that was likely worsening, inability to care for self, poor medication adherence, frequent falls, balance problems, and decreased energy. The record also showed that Resident R64 had a Durable Health Care POA naming Resident Representative RR1 effective 12/13/23, and the pre-admission paperwork listed RR1 as the emergency contact. A nursing progress note documented that the resident was very confused and slightly agitated. A social work note stated that two cousins visited and discussed family concerns about the current POA, while the facility record did not include documentation that attempts were made to contact the POA. The admission agreement was signed by Resident R64 on 8/22/25. During interviews, the NHA stated the facility’s binding arbitration agreement was included in the admission paperwork and reviewed at admission, and later stated the resident signed his own paperwork because no one was answering the phone and the family thought the POA was stealing his money. The NHA and social worker also referenced a psychology note from 12/29/25 stating the resident had cognitive deficits and memory gaps and needed a POA to help with medical, financial, and other decisions, while also noting he was only mildly cognitively impaired and could choose who to assign as POA. The NHA ultimately confirmed the facility failed to ensure residents had the capacity to understand the terms of a binding arbitration agreement for Resident R64.
Failure to Obtain Representative Consent for Arbitration Agreement
Penalty
Summary
The facility failed to obtain consent for a binding arbitration agreement from the resident representative for one of three sampled residents, Resident 19, who did not have the capacity to make decisions. Resident 19’s record showed admission on 11/14/2001 and re-admission on [DATE] with diagnoses including metabolic encephalopathy. The MDS dated 10/30/2024 and 3/26/2026 indicated severely impaired cognition, and the H&P dated 10/25/2024 noted fluctuating capacity to understand and make decisions, while the H&P dated 1/23/2026 stated the resident did not have capacity to understand and make decisions. The arbitration agreement dated 10/24/2024 contained Resident 19’s signature. During interviews, the AD and AA stated the arbitration agreement is explained at admission and that the resident nodded when it was explained, but they did not verify whether the resident lacked capacity or check with nursing staff about the resident’s ability to make an informed decision. The AD stated the importance of making the resident or responsible party aware that signing the arbitration agreement means giving up the right to go to court. The DON stated that if a resident lacks capacity, signing the arbitration agreement would not be accurate. The facility policy stated the resident or representative must be given the terms in a manner understood, must verbally acknowledge understanding, and that a signature alone is not sufficient.
Arbitration Agreement Missing Required Resident Rights Language
Penalty
Summary
The facility failed to ensure its Arbitration Agreement explicitly stated that neither the resident nor the resident’s representative was required to sign a binding arbitration agreement as a condition of admission or as a requirement to continue receiving care, and it also failed to state that the agreement allowed communication with federal, state, or local officials, including surveyors and the Office of the State Long Term Care Ombudsman. This deficiency was identified for one resident reviewed for arbitration agreements, Resident #73, whose record showed admission on 02/01/2023 with diagnoses including atherosclerotic heart disease, polyneuropathy, insomnia, contracture of the left elbow, lack of coordination, muscle weakness, dementia, abnormal posture, COPD, dysphagia, hypertension, cognitive communication deficit, alcohol abuse, gastro-esophageal reflux, and chronic hepatitis. The most recent MDS showed a BIMS score of 15, indicating the resident was cognitively intact at the time of the assessment. During interview, the resident explained the purpose of the facility arbitration agreement but was not willing to review the signed agreements from 02/03/2023 or 03/25/2026 and could not explain why the agreement was resigned. Review of the 02/03/2023 agreement showed it did not contain the required statement that signing was not a condition of admission or continued care, and it did not state that the resident or anyone else could communicate with federal, state, or local officials, including surveyors, health department employees, or the State Long Term Care Ombudsman. The Admission Director confirmed these omissions and stated the resident’s agreement did not meet requirements when it was requested during the survey process.
Arbitration Agreement Missing Required Communication Language
Penalty
Summary
The facility failed to ensure its binding arbitration agreement included language stating that the resident or anyone else, including a resident representative, was allowed to communicate with federal, state, or local officials, including federal and state surveyors, other health department employees, and representatives of the Office of the State Long Term Care Ombudsman. This omission was identified for three of three sampled residents reviewed for the Arbitration Facility Task: Residents 33, 75, and 93. Resident 33 was admitted with diagnoses including major depressive disorder and anxiety disorder. The resident’s H&P stated the resident could make needs known but could not make medical decisions, and the MDS indicated the resident had impaired cognition but could make self-understood and understand others, with a family member participating in assessment and goal setting. Resident 33 electronically signed the arbitration agreement, but the agreement did not contain the required communication language. Resident 75 was admitted and later readmitted with diagnoses including depression and systolic heart failure. The H&P stated the resident had capacity to understand and make decisions, and the MDS indicated intact cognition. Resident 93 was admitted and later readmitted with diagnoses including acute embolism, thrombosis of deep veins in the lower extremity bilaterally, and diverticulitis of the intestine; the H&P stated the resident had capacity to understand and make decisions. Both residents also signed arbitration agreements that did not include the language allowing communication with the listed officials. During interviews, the Admissions Coordinator and Administrator stated the language was not on the facility’s arbitration agreement and agreed it should be included so residents know they can communicate with those entities. The facility’s policy on Arbitration stated the agreement may not contain language that prohibits or discourages such communications.
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