Failure to Provide Private Telephone Access for Residents
Summary
The facility failed to ensure residents had reasonable access to and privacy in their use of telephones, affecting three sampled residents. Resident 1, admitted with diagnoses including diabetes mellitus and chronic kidney disease, had intact cognition and required substantial assistance with transfers and walking. Resident 3, with diabetes mellitus and atrial fibrillation, had mildly impaired cognition and required supervision or moderate assistance with mobility. Resident 2, with heart failure and chronic kidney disease, had moderately impaired cognition and was dependent on staff for transfers. These residents relied on staff and facility resources to access telephones for personal communication. Staff interviews and observations showed that, following a change in facility ownership, the previous owner confiscated all work phones and residents’ phones for private use, and the facility no longer had a dedicated resident cell phone. RN 1 reported that residents who were able to ambulate used the phone at the nursing station, while bedbound residents used the nursing staff’s work cell phone, which contained sensitive information about many residents. Because of this, staff remained with residents during calls to prevent access to confidential information on the device, acknowledging that this could be a violation of privacy since staff could hear the conversations, even though they tried not to listen. Resident interviews and direct observations confirmed the lack of private telephone access. Resident 2, who was bedbound, stated she previously spoke with her daughter weekly but had been unable to do so for a couple of months because the facility no longer allowed her to use the phone and she could not get out of bed to reach the nursing station phone. Resident 3 stated that when he needed to use the phone, he did so at the nursing station and had conversations in front of staff. Resident 1 was observed using the phone at the nursing station while RN 1 sat nearby. The Social Services Director and the Administrator both confirmed that, as an interim measure, residents were using the RN supervisor’s work cell phone under staff monitoring, which prevented residents from having private telephone conversations. Facility policies on confidentiality and resident rights stated that residents would have their written and telephone communications protected and would have access to a telephone with privacy, which was not being met in these instances. These failures resulted in Resident's 1, 2, and 3 being unable to make personal phone calls without staff's presence and monitoring, violating their rights to private communication. These deficient practices had the potential to cause psychosocial harm, including fear of being overheard when discussing personal information, and feelings of distress and isolation due to lack of communication with family.
Penalty
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The facility failed to ensure residents received their mail in a timely manner, particularly mail delivered on Saturdays. During a council meeting, several residents reported that Saturday mail was not brought to them until Monday. The new Activity Director did not work weekends and was unfamiliar with the weekend mail process. The weekday receptionist stated that the weekend receptionist had no key to the outdoor mailbox, so mail was not retrieved on Saturdays unless the Business Office Manager was present. The Business Office Manager confirmed that when she was absent on weekends, no one else could access or deliver residents’ mail, and that after the prior Activity Director left, there was no designated staff to deliver weekend mail, resulting in periods when residents did not receive their mail on the day it arrived.
Resident mail was not delivered on Saturdays for four residents who raised the issue during Resident Council. Residents reported that Saturday mail was left at the front desk and not sorted and delivered until Monday, while the secretary said she handled mail Monday through Friday and the weekend nursing supervisor was responsible. An RN said she was unaware weekend mail delivery was part of her duties and did not have time to do it when she was the only nurse in the building. The Administrator stated weekend mail was typically delivered Monday, despite the facility policy requiring mail delivery six days a week.
A resident with multiple chronic conditions, who relied on phone contact with a seriously ill significant other, lost access to private communication after her personal cell phone was broken and sent out for repair. Facility policy guarantees residents access to a telephone and private communication, but there was no cordless phone available on the relevant hall, and staff, including the DON, SSD, and Administrator, confirmed there was no convenient method for residents on that hall to make private calls without arranging to use a staff office. This resulted in the resident having no readily available, private telephone option.
A resident with no cognitive impairment reported that her personal packages were repeatedly delivered already opened, causing her concern and discomfort. Staff interviews revealed that while mail and packages for residents were supposed to be sorted at reception and delivered unopened by Life Enrichment staff, this resident’s packages were routinely held so the DON could open and inspect them in the reception area or office before delivery, with only approved items passed on. Life Enrichment staff confirmed they picked up the resident’s packages already opened and told her the DON had to review the contents first. The Administrator stated staff should not open resident mail or packages except in front of the resident with consent, and both the Administrator and DON acknowledged there was no signed permission from the resident, despite a facility policy stating that mail may not be opened without the resident’s permission.
Delayed Resident Mail Distribution: The facility failed to ensure residents had timely access to incoming mail for 8 of 8 confidential residents reviewed. Residents stated they did not receive mail on Saturdays and expected mail that day if they were expecting it. The AD, ADM, and Transportation Manager gave inconsistent accounts of weekend mail retrieval, and the facility policy on Resident Personal Mail did not address Saturday mail distribution.
A cognitively intact resident with psychiatric and respiratory diagnoses was on a speaker-phone call with family in a common area where multiple people could hear the conversation, and the resident stated she could not move to a private location. An unknown staff member then intervened, told the family they would need to come in and speak with the DON if they wished to talk to the resident, and abruptly ended the call. The Administrator and Social Services Designee confirmed that the resident was not offered or provided a private place for the call and that staff terminated the conversation, contrary to the facility’s written policy guaranteeing residents private access to telephone communication.
Failure to Ensure Timely Weekend Mail Delivery to Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ right to receive mail, including mail delivered on Saturdays. During a Resident Council group interview, several residents reported that when mail was delivered to the facility on Saturdays, it was not distributed to them until Monday by the Activity Director. Multiple residents agreed with this account, and no residents present disagreed. The new Activity Director, who had transitioned from working as a Certified Occupational Therapist Assistant on 04/24/26, stated she did not work weekends and was unsure how mail delivery to residents was handled on weekends. Staff interviews further showed that the weekend receptionist did not have a key to the outdoor mailbox and therefore could not retrieve Saturday mail. The weekday Receptionist reported that she collected the mail from the outdoor mailbox on Monday mornings and gave it to the Business Office Manager, after which the Activity Director delivered it to residents. The Business Office Manager confirmed that if she was not at work on weekends, no one else had access to the outdoor mailbox. She stated she worked most Saturdays, checked and sorted the mail, and then gave residents’ mail to activity staff or delivered it herself, but noted that after the previous Activity Director left 6–7 weeks earlier, there was no one designated to deliver mail to residents on weekends when she was not present. The Administrator acknowledged that there were approximately three weeks when weekend mail was not delivered to residents due to turnover in the activity department and the absence of an Activity Director.
Resident mail not delivered on Saturdays
Penalty
Summary
The facility failed to ensure resident mail was delivered to residents on Saturdays for four residents who raised the concern during Resident Council. During the 4/30/26 Resident Council meeting, R24 stated that mail delivered by the post office on Saturdays was left on the receptionist's desk near the front entrance and then sorted and delivered by the receptionist on Monday morning. R33, R34, and R14 confirmed that Saturday mail was not delivered to residents. During interviews, the secretary stated that she sorted and delivered mail Monday through Friday, and that weekend mail delivery was the responsibility of the nursing supervisor. An RN stated she was unaware that collecting and passing mail was part of her weekend responsibilities and said she did not have time to deliver mail when she was the only nurse in the building overseeing all staff and residents. The Administrator stated it was the responsibility of the secretary at the front desk to deliver mail and acknowledged that mail delivered over the weekend was typically delivered Monday after front desk staff arrived, although her expectation was that mail would be delivered the same day it was delivered to the facility. The facility policy stated resident mail was to be delivered six days a week, Monday through Saturday, in a timely fashion.
Failure to Ensure Resident Access to Private Telephone Communication
Penalty
Summary
The facility failed to ensure a resident’s right to reasonable access to and privacy in the use of a telephone for communication. Facility policy on Resident Rights, revised December 2016, states that residents are guaranteed access to a telephone, mail, and email, and the ability to communicate in person and by mail, email, and telephone with privacy. Resident #1 was admitted on 12/18/24 with diagnoses including Sjogren syndrome, rheumatoid arthritis, chronic kidney disease, and morbid obesity. During an interview, the resident reported that she had dropped and broken her personal cellular telephone, which she had used for private communication, and that the facility did not have any telephone that was convenient for her to use privately. She stated that no staff had offered her the use of a staff office or any other mechanism for private communication, and she was upset because she relied on telephone contact with her significant other, who had cancer and was unable to visit. Observations and staff interviews confirmed the lack of accessible, private telephone options for residents on South Hall. An observation on the 100 Hall revealed there was no cordless telephone available for resident use. The DON confirmed that the facility did not have a method to provide residents on South Hall with private communication without first making arrangements or an appointment to use a staff office, and that the cordless telephones in the facility did not have sufficient range to reach South Hall. The SSD confirmed there were no cordless telephones at the South Hall nurses’ station that could be taken to residents’ rooms and acknowledged that Resident #1’s cell phone had been broken and sent out for repair. The Administrator also confirmed that residents on South Hall did not have a method for private communication without prior arrangements and acknowledged that access to private communication is a guaranteed resident right.
Failure to Protect Resident’s Right to Unopened Personal Mail and Packages
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s right to receive unopened personal mail and packages. Resident 1 (R1), who had no cognitive impairment per the facility assessment, reported that her packages had been delivered to her already opened without her consent, causing her concern and discomfort. R1 stated she did not want anyone but herself to open her packages and that she had been told the DON (V2) was opening her packages before they were delivered to her. Interviews with staff confirmed that all resident mail and packages were received at the reception area, sorted by room number, and then delivered by Life Enrichment staff, with the expectation that they remain unopened. However, staff reported that R1’s packages were held so the DON could open and inspect the contents in the reception area or in the DON’s office before delivery, and that only approved items were then sent on to R1. Life Enrichment staff stated they had picked up R1’s packages already opened and informed R1 that the DON had to go through her items first. The Administrator (V1) stated staff should not open any resident’s mail or packages and that, if needed, packages should be opened in front of the resident with the resident’s consent. Both the Administrator and DON confirmed there was no signed contract or permission from R1 authorizing staff to open her packages, and the facility’s Resident Rights policy states that the facility may not open a resident’s mail without the resident’s permission.
Delayed Resident Mail Distribution
Penalty
Summary
The facility failed to ensure residents had reasonable access to receive their mail in a timely manner for 8 of 8 confidential residents reviewed for mail. During a confidential group interview, the 8 residents stated they did not receive mail on Saturdays and expected to receive mail that day if they were expecting it. The facility did not have a system in place to distribute incoming mail daily and ensure residents promptly received their mail. During interviews, the AD stated she was responsible for ensuring residents received mail on weekdays and that she went to the post office and delivered mail to residents throughout the week, but she was unsure whether the post office was open on Saturdays. The ADM stated he was unsure if staff could obtain mail on weekends, while also stating the AD and transportation manager alternated weekends to obtain mail. The Transportation Manager stated she was on call every other weekend, went to the post office to obtain mail, and distributed it to residents, and that if a resident was expecting mail and did not receive it, she would expect them to be upset. A review of the facility policy titled Resident Personal Mail, last updated 06/2017, showed it did not address receiving and distributing mail on Saturdays.
Failure to Provide Resident Privacy During Telephone Communication
Penalty
Summary
The facility failed to ensure a resident had privacy during a telephone call with family, as required by resident rights and the facility’s own policy. The resident, admitted in mid-February 2026, had diagnoses including schizophrenia, anxiety, adjustment disorder with mixed anxiety and depression, and emphysema, and was documented as cognitively intact on the admission MDS. An audio recording of a family-initiated call to the facility’s telephone showed that the resident accepted the call and identified herself, along with her son and daughter-in-law. During the call, the resident told her family she was on speaker phone with many people around listening. When her son asked if she could go somewhere private, the resident stated she could not. The audio recording further revealed that an unknown facility employee intervened in the call, told the family that if they wished to speak with the resident they would need to come to the facility and speak with the DON, and then abruptly ended the call. The Administrator confirmed that the recording involved the resident, her family, and an unknown staff member, and verified that privacy was neither offered nor provided and that a staff member abruptly terminated the call. The Social Services Designee reported being contacted by the night shift nurse about the family’s request to speak with the resident and stated she had advised that if the resident wanted to speak with her family, staff could not stop her. She also verified that the resident was not provided a private place for the call and that an unknown staff member abruptly ended the conversation. Review of the facility’s Resident-Patient Rights policy, revised February 2026, showed that residents were to have access to telephone communication with privacy, which was not afforded in this incident.
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