Failure to Honor Cognitively Intact Residents’ Right to Free Movement and Outdoor Access
Summary
The facility failed to honor residents' rights to self-determination and freedom of movement by restricting cognitively intact residents from independently accessing other areas of the building and the outdoors. During a Resident Council group interview, three residents living on the third floor reported they were prohibited from going to the first floor or the outdoor patio without staff supervision. Barriers included an elevator that required a keypad code, which was not shared with residents, and a locked exterior door to the patio. These restrictions prevented them from visiting common areas such as the first-floor aquarium, the lobby, and the outdoor seating area at will; one resident reported being prevented from going to the lobby to collect cups for coffee the previous evening. All three residents expressed a desire for independent access to facility amenities and the outdoors and stated the facility felt like a prison. Record review showed that each of the three residents was assessed as cognitively intact and without hallucinations, delusions, or behavioral issues. One resident had diagnoses of anxiety, depression, and vitamin D deficiency, and her MDS indicated it was very important for her to go outside for fresh air when weather permitted. Another resident had anxiety, vitamin D deficiency, and psoriatic arthritis, was able to transfer independently in her wheelchair, and her MDS also indicated it was very important for her to go outside for fresh air when weather permitted. The third resident had type 2 diabetes, insomnia, heart failure, chronic pain, and Parkinson's disease, was able to transfer independently in his wheelchair, and his MDS likewise documented that it was very important for him to go outside for fresh air when weather permitted. Care plans for all three residents documented that they enjoyed going outside in good weather and were to participate in activities of their choice, with assistance or reminders as needed. However, the March activities calendar for the third floor contained no scheduled outdoor activities. The AD stated that residents could go outside only when weather permitted and when a staff member was available to accompany them, and that some residents would be fine to go outside unsupervised but corporate required supervision. The DON confirmed that third-floor residents were not given the elevator code because some residents on that floor were elopement risks, that the outside patio door was locked due to a past elopement, and that aides did not have time to take residents downstairs or outside, so they were to contact the AD to do so. The Administrator acknowledged there was no policy for keeping the third floor secured, that residents were not allowed to have the elevator code, that residents had to be supervised to go outside, and that there was no policy for residents going outside, despite a facility Resident Rights policy stating residents must be able to exercise their rights without interference, coercion, discrimination, or reprisal.
Penalty
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Failure to Offer Choice of Hospice Provider: The facility did not ensure that 3 residents receiving hospice services were offered a choice of hospice provider. Medical record review showed no evidence that the residents were given provider choice, and an RCD confirmed that prior to the operator transition, hospice residents were not given a choice. The facility's Resident Rights policy states residents have the right to choose health care and providers of health care services.
Failure to honor a resident’s request for nail care. A resident with dementia, renal insufficiency, HTN, and depression had long fingernails beyond the fingertips and stated staff had not trimmed them despite repeated requests. Staff said nail care was usually done on shower days, but also stated that if a resident asked for nail trimming, an NA, wellness staff, or an LPN/RN could complete it and the resident should not have to wait until the next bath day.
A resident with MS, neuromuscular dysfunction of the bladder, and quadriplegia was cognitively intact and dependent on staff for ADLs, with a care plan preference not to be gotten up into a w/c until after 11:00 a.m. The resident stated staff repeatedly dressed and transferred the resident earlier than requested, and during observation the resident was already dressed and seated in an electric w/c after being gotten up at 9:30 a.m. A NA said she did not reference the care guide for the resident's preferred time, while the DON stated staff were expected to honor the preference and that it should have been listed on the daily NAR guide.
A resident with dementia, anxiety, and depression had a family-requested staffing preference that a specific CNA not provide care due to a prior skin-care concern. Although an LN, the DSD, and the DON were aware of this request, it was not documented in the resident’s care plan or on the unit’s patient preference list. As a result, staffing assignments placed the restricted CNA on the resident’s hall, and documentation showed that this CNA provided incontinent care to the resident, contrary to the expressed preference and facility policies on accommodation of needs and dignity.
The facility failed to honor resident rights to self-determination by not allowing residents and their families to choose a preferred medical transportation provider for offsite dialysis and other appointments. One resident with multiple chronic conditions and moderate cognitive impairment requested to use Medical Transportation B but was told by staff that this company could not come on the premises, and her care plan listed only Medical Transportation A. Another resident with end stage renal disease and communication deficits had a family member who requested continued use of Medical Transportation B, which had transported him at home, but the DON stated the facility used Medical Transportation A under contract and did not allow Medical Transportation B. A third resident with encephalopathy, amputation, and ESRD had a family member and POA who preferred Medical Transportation B to maintain consistency, but she was told the parent company would not allow that provider. The Administrator of Medical Transportation B reported being informed by the facility’s Administrator and DON that the facility only used Medical Transportation A, despite facility documents referencing resident rights and resident/responsible party responsibility for arranging transportation.
A resident who was cognitively intact stated he wanted 3 showers weekly but was receiving showers only 2 times per week. Records showed his bathing preference was documented on admission, yet bathing logs from several weeks reflected only twice-weekly showers. The VP of Risk Mgmt confirmed the resident was receiving showers twice weekly, despite the resident's stated preference and the facility policy supporting resident choice.
Failure to Offer Choice of Hospice Provider
Penalty
Summary
The facility failed to ensure residents' right to choose their health care providers for 3 of 12 sampled residents reviewed for hospice services. Resident #26 began receiving hospice services on 1/2/26, resident #83 began receiving hospice services on 1/21/26, and resident #84 began receiving hospice services on 2/5/26, but the medical record review showed no evidence that any of these residents were offered a choice in hospice provider. During an interview on 5/6/26 at 12:44 PM, the regional clinical director confirmed that prior to the operator transition, residents on hospice were not given a choice for hospice provider. The facility's Resident Rights policy, last revised on 6/10/25, states that the resident has the right to choose health care and providers of health care services consistent with his or her interests, assessments, and plan of care.
Failure to Honor Resident Request for Nail Care
Penalty
Summary
The facility failed to honor a resident’s preference for nail care and did not ensure the resident’s nails were trimmed when requested. The resident had an annual MDS assessment showing moderate cognitive impairment and diagnoses including non-Alzheimer’s dementia, renal insufficiency, hypertension, and depression. The care plan noted limited range of motion in the upper extremities and assistance needs for bathing, showers, grooming, oral care, and dressing. Progress notes showed the resident’s last shower on 4/3/26, but nail care was not addressed in the notes. During observation, the resident was seated in a wheelchair with long fingernails extending beyond the fingertips and stated the nails were too long and that staff had not trimmed them despite requests. A nail clipper was kept on the bedside table because the resident wanted the nails trimmed. On later interviews, the resident again stated the nails had not yet been trimmed and that it bothered them. Staff interviews showed nail care was typically done on shower days, but multiple staff members stated that if a resident requested nail trimming, either nursing assistants, wellness staff, or the nurse could do it, and the DON stated residents should not have to wait until the next bath day for nail trimming.
Failure to Honor Resident Preference for Morning Care Timing
Penalty
Summary
The facility failed to honor a resident's right to make choices about aspects of care for 1 of 2 residents reviewed for self-determination. The resident was cognitively intact per the comprehensive MDS, had clear speech, could make self understood, and could understand others. The resident's diagnoses included multiple sclerosis, neuromuscular dysfunction of the bladder, and quadriplegia, and the resident was dependent on staff for ADLs. The care plan indicated the resident required assistance of two with Hoyer transfers, assistance of one with ADLs, and that the resident should not be gotten up into a wheelchair until after 11:00 a.m. per preference. During interview, the resident stated that several times requested to get up after 11:00 a.m. but staff consistently dressed and transferred the resident to the wheelchair earlier in the morning. The resident became tearful and stated, "makes me feel I'm in the land of misfit toys." During observation, the resident was dressed and seated in an electric wheelchair, and the bed was made; the resident stated two aides got the resident up at 9:30 a.m. and basically said it was "now or never." A NA stated the care guides indicated resident preferences and care needs, but did not usually work with the resident and did not reference the care guide for the resident's preferred time request. The DON stated the care plan reflected the resident's preference not to get up until 11:00 a.m. and expected staff to honor it, and stated the preference should have been listed on the daily NAR guide. The resident's NAR guide stated, "Don't get up the pt before 11 AM."
Failure to Honor Resident Staffing Preference for CNA Assignment
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s known staffing preference regarding which CNA should provide care. Resident 1, who had dementia, anxiety, and depression, had a family request made in December 2025 that CNA 1 not provide care to the resident due to concerns related to a prior care encounter involving a skin issue. During interviews and record reviews, LN 1 stated that CNA 1 was not to care for this resident per the family’s request. However, the facility’s [nurses’ station] Patient Preferences document, updated as of 3/11/26, only indicated that the resident preferred CNA 2 when she was present and did not indicate that CNA 1 was restricted from providing care. Further review showed that Resident 1’s comprehensive care plan, last reviewed on 4/22/26, did not reflect the family’s staffing request and lacked interventions to communicate this preference to direct care staff. The Nursing Staffing Assignment and Sign-in Sheet for 4/12/26 showed CNA 1 was assigned to the unit including the resident’s room, and incontinent care documentation for that date showed CNA 1 provided care to the resident. The DSD confirmed the family’s request via text message that CNA 1 not provide care, acknowledged it was not documented in the Patient Preferences list or care plan, and confirmed CNA 1 did provide care on 4/12/26. The DON also confirmed that the request was not reflected in the care plan or preference list and that CNA 1 provided care, despite facility policies on Accommodation of Needs and Dignity stating that resident needs, choices, and preferences are to be respected and honored to the extent possible.
Failure to Honor Resident Choice of Medical Transportation Provider
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to self-determination and choice regarding transportation providers for offsite medical appointments, particularly dialysis. One resident with type II diabetes, heart failure, glaucoma, COPD, and end stage renal disease, who had a BIMS score of 11 indicating moderate cognitive impairment, was care planned to receive dialysis three times a week with transportation by Medical Transportation A. This resident stated she told two staff members she wanted to use Medical Transportation B instead, but was told no and informed that Medical Transportation B could not come on the premises. She reported there was nothing wrong with Medical Transportation A, but expressed a preference for Medical Transportation B because of familiarity. Another resident with cerebral infarction, dysphagia, and end stage renal disease, who had documented communication problems with impaired ability to make self-understood and to understand others, also received dialysis three times a week offsite. His family member, listed as emergency contact and responsible party, reported that he had used Medical Transportation B when at home and requested that the facility use Medical Transportation B for dialysis transport. The DON documented a conversation with this family member, assuring her that the facility had arranged safe and reliable stretcher transportation through Medical Transportation A and reiterating that transportation was already set up. The family member stated she was told Medical Transportation A had a contract with the facility, that there was no contract with Medical Transportation B, and that Medical Transportation B was not allowed in the facility, leaving her feeling she had no choice in the matter. A third resident, with traumatic amputation of the left lower leg, encephalopathy, end stage renal disease, type II diabetes, and COPD, was also care planned to receive dialysis three times a week with transportation by Medical Transportation A and had impaired cognitive function or thought processes. His care plan included interventions to communicate with the resident, family, and caregivers regarding his capabilities and needs, and to keep his routine and caregivers as consistent as possible. His family member and healthcare power of attorney stated they preferred to use Medical Transportation B, which had transported him three times a week for years when he lived at home, and asked staff to call Medical Transportation B for his appointments. She reported being told that Medical Transportation B was not allowed to come into the facility because the parent company would not allow it. The Administrator of Medical Transportation B confirmed that whenever their patients were placed at this facility, they were not allowed to provide transportation and that the facility Administrator and DON had told her they only used Medical Transportation A. Facility education materials and the Resident Admission Agreement referenced resident rights and resident/responsible party responsibility for arranging transportation, but the facility’s practice limited residents’ and families’ ability to choose their preferred transportation provider.
Resident Bathing Preference Not Followed
Penalty
Summary
The facility failed to ensure a resident received showers and bathing according to his preference. During an interview, the resident stated he was receiving showers twice weekly but wanted three showers a week, and he did not remember staff asking him about his shower and bathing preferences. The resident was cognitively intact per a quarterly MDS assessment, and his record showed a bathing preference documented on admission as a bed bath three times weekly. The care plan identified an ADL self-care performance deficit and included staff assistance with showering and bathing. However, bathing documentation from 3/1/26 through 4/16/26 showed the resident was scheduled for and received showers only twice weekly. During interview, the VP of Risk Management confirmed the resident received showers twice weekly and stated that if the resident told the admitting nurse he wanted a shower three times a week, it should have been scheduled accordingly. The facility policy stated residents have a right to make their own schedule.
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