Failure to Provide Requested Facility Policies to Resident Representative
Summary
The deficiency involves the facility’s failure to provide a resident’s representative with requested facility policies necessary to support participation in the person-centered care planning process. The resident involved was admitted on 08/12/24 and had multiple diagnoses, including chronic kidney disease stage IIIA, hypertension, hyperlipidemia, polyneuropathy, osteoarthritis, dementia, hypothyroidism, chronic pain, generalized muscle weakness, cardiac murmur, amnesia, photokeratitis, and dermatitis. The most recent quarterly MDS assessment showed a BIMS score of three, indicating severe cognitive impairment, and documented that the resident required at least limited assistance with all activities of daily living, including eating, hygiene, toileting, dressing, transferring, and ambulation. Between 03/30/26 and 04/02/26, interviews with family and staff revealed that the resident’s daughter requested facility policies related to medication administration and bed alarms, but the facility did not provide them. In an interview on 04/01/26 with the Administrator, the Regional Director of Operations, and the Regional Director of Clinical Services, facility leadership confirmed that the daughter had requested these policies and that they were not provided. During the exit conference on 04/02/26, the Regional Director of Operations again acknowledged that the request was not fulfilled and explained that the facility did not provide the policies because they were undergoing revisions and the facility could not ensure distribution of updated versions. Review of facility policies further showed there was no policy addressing the provision of facility policies to residents or their representatives upon request.
Penalty
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Resident rights were not reviewed verbally or in writing during resident council meetings, and the posted rights notice was outdated. Several residents stated the rights had not been reviewed, and the admin confirmed the meetings did not include this review and the poster was not current.
Failure to Review Resident Rights in Council Meetings: Four cognitively intact residents who regularly attended resident council meetings did not recall resident rights ever being discussed, and meeting minutes did not document any review of rights. A resident rights poster was posted in a hallway, but the residents said they did not know where it was located. The LED could not find documentation that rights were reviewed, and the Admin said the process was not yet standardized.
A resident admitted after a hospital stay did not have a signed admission Agreement in the EMR, resulting in no documented written notice of rights, services, or charges. The Director of Guest Services described a standard process of assessing cognition, reviewing the Agreement with the resident or representative, and obtaining a signature within about 72 hours, but could not locate a completed Agreement for this resident and noted she had been the only Guest Services staff and was on vacation around the time of admission. A blank Agreement reviewed by surveyors showed that non‑covered service prices auto‑populate when the form is completed. The BOM and SSD confirmed that written information on room rates and non‑covered costs is contained in the admission Agreement and acknowledged that, for this resident, they only discussed costs verbally with the resident and her daughter, without any written documentation.
A resident with multiple medical conditions and mild cognitive impairment was admitted with a family member holding POA present, but the facility failed to provide or review the admission packet that includes resident rights, rules, responsibilities, charges, and advance directive information. The EMR contained no admission packet or agreement, and the advance directives section was left blank. The Admissions Coordinator acknowledged that no packet was created or given, did not review packet contents with residents or representatives, and intentionally withheld the packet pending POA confirmation, despite POA documentation being available. The family member reported never receiving any rights information or documentation, while the Administrator stated the packet is the primary means of communicating rights and resident wishes; later, the resident received CPR despite having DNR wishes handled by the hospital.
A Spanish‑speaking resident with dementia, severe cognitive impairment (BIMS 5/15), and multiple ADL assistance needs had a care plan identifying a communication problem, a preference for Spanish, and an intervention to provide a translator as necessary. The H&P documented a language barrier and noted that one of two nurses could speak Spanish, and the DON stated an interpretation document was kept at the nurse’s station. However, CNAs caring for the resident reported they were not aware of any interpreter services or interpreter information, demonstrating that interpreter services were not effectively available or communicated to staff to support this resident’s identified communication needs.
The facility failed to ensure the current RBOR was posted for residents, visitors, and staff and provided to all residents. Surveyors found outdated 2016 RBOR postings and paper copies in common areas, while the admission packet contained a newer RBOR. SS staff said updated pamphlets were ordered for new admissions, but residents admitted earlier had not been informed of the update, and the administrator was unaware the RBOR had changed.
Resident Rights Not Reviewed or Posted Current
Penalty
Summary
The facility failed to ensure the resident bill of rights were provided verbally and in writing for all residents. During review of Resident Council Minutes Forms for 2/24/26, 3/26/26, and 4/16/26, the minutes did not document that the resident rights were reviewed. When seven residents attended a resident council meeting held by the surveyor, the residents stated the rights had not been reviewed. One resident said the rights were given at admission and posted in the facility, while another resident said they had been admitted years ago and were not coherent at that time. At 11:45 a.m., the poster near the nurses' station was reviewed and was dated 9/19, not the current 12/25 resident rights poster. During interview, the administrator stated the life enrichment supervisor was responsible for the resident council meetings and verified that the resident rights were not reviewed during those meetings and that the poster was not current. The facility policy for Resident and Family Council stated the facility would provide meeting space, inform residents of meeting opportunities, and respond to council concerns, but it did not include review of resident rights in the agenda.
Failure to Review Resident Rights in Council Meetings
Penalty
Summary
The facility failed to provide ongoing communication to residents about their rights through resident council meetings for 4 of 4 cognitively intact residents who attended those meetings. Quarterly MDS assessments for R33, R34, R14, and R24 indicated each resident was cognitively intact. However, resident council meeting minutes from November 2025 through April 2026 did not show that resident rights were reviewed or discussed during the meetings. During a resident council meeting on 4/30/26, R33, R34, R14, and R24 stated they regularly attended the meetings and did not recall any time when resident rights had been discussed. All four residents stated they did not know where resident rights were posted in the facility, although a resident rights poster was hung in a hallway across from the beauty salon. The life enrichment director stated she took minutes for resident council meetings and described the usual meeting format, but she could not find documentation showing resident rights were discussed. The administrator stated resident rights were reviewed upon admission and said that if social workers attended resident council, they would be responsible for reviewing resident rights, adding that the facility was working on standardizing this process.
Failure to Provide Written Admission Agreement and Cost Information
Penalty
Summary
The facility failed to provide a signed admission Agreement that included a written notice of resident rights, services, and charges for one resident. Record review showed that this resident was admitted following a hospital stay, but the resident’s file did not contain any signed admission Agreement. During a side‑by‑side record review and interview, the Director of Guest Services described the usual process for obtaining a signed admission Agreement, which involved assessing the resident’s cognition or checking a BIMS score, then reviewing and signing the Agreement with the resident if cognitively intact, or with a POA, spouse, or other family member if not. She stated this was typically completed within about 72 hours, depending on family availability, and that the Agreement could be executed via electronic signature. A blank admission Agreement reviewed during the survey did not have prices for non‑covered services filled in, and the Director of Guest Services explained that when she populated the form with the date, the prices and costs of services would automatically populate. When asked to locate the signed admission Agreement for this resident, the Director of Guest Services searched the EMR and confirmed there was none, stating she did not know what happened but recalled she was the only person in Guest Services at the time and had taken a vacation during that period. When questioned about written notice of costs for services not covered once the resident’s benefits ended, the Director of Guest Services stated that the resident or representative would have had a conversation with the Business Office Manager (BOM) and/or Social Services Director (SSD). In a separate interview, the BOM and SSD stated that written information about room rates and non‑covered costs was contained in the admission Agreement and acknowledged that, for this resident, they had only verbal conversations with the resident and her daughter about costs, with no documentation of written notice.
Failure to Provide Admission Packet and Communicate Resident Rights and Advance Directives
Penalty
Summary
The deficiency involves the facility’s failure to inform a resident, both orally and in writing, of her rights, rules, responsibilities, and facility policies at the time of admission. The resident was an elderly female admitted with diagnoses including UTI, history of colon cancer and large intestine, hypertension, irregular heartbeat, presence of a pacemaker, and mild cognitive impairment, with a BIMS score of 12/15 indicating moderately impaired cognition. Her face sheet listed a family member as Emergency Contact and POA for healthcare, and her advance directives section was blank. Progress notes documented that she arrived in the evening by EMS, was A&O x2, oriented to the room and equipment, and did not voice concerns at that time. However, the electronic medical record contained no admission packet or admission agreement for her. Interviews with facility staff revealed inconsistent and incomplete practices regarding the admissions packet, which contained resident rights, rules governing resident conduct, responsibilities, charges, and advance directive information. The Administrator stated that resident rights were communicated through the admissions process and packet, and that the Admissions Coordinator and Marketing were responsible for completion of the packet, which should be provided before or at admission and completed within 72 hours. The DON similarly stated that the packet was sent prior to arrival and completed shortly after admission. In contrast, the Admissions Coordinator initially described her role as getting the room ready and ensuring a good stay, and stated she was not responsible for reviewing documentation. She later stated she was responsible for the admission packet, usually completed after admission and provided via email or in person within 48 hours, but that she did not review the packet contents with residents or their representatives. For this resident, the Admissions Coordinator acknowledged that no admission packet was created or provided, and that the resident’s POA, who was present at admission, never received the packet or any communication of resident rights or other packet contents. She stated she intentionally did not send the packet because she had not yet confirmed the POA status, even though the executed POA was included in documentation received before and after admission. The family member/POA reported that the resident was very confused and distressed on admission, repeatedly stating that people were trying to kill or harm her, and that the family member never received an admission packet or any documentation of rights or other information. The Administrator stated that failure to deliver or communicate the contents of the admissions packet could leave residents unaware of their rights and the facility unaware of residents’ wishes. The record also showed that the resident’s advance directives were not documented in the facility record, and on a later date she received CPR when unresponsive despite her wishes being DNR, with the hospital having handled the DNR paperwork.
Failure to Ensure Access to Interpreter Services for Spanish-Speaking Resident
Penalty
Summary
Facility staff failed to ensure language interpreter services were available to allow effective communication for a Spanish‑speaking resident. The resident had Type 2 diabetes without complications and Alzheimer's disease, and a recent MDS assessment showed a BIMS score of 5/15, indicating severely impaired cognitive abilities for daily decision‑making. The MDS also documented that the resident required varying levels of assistance with oral hygiene, dressing, eating, toileting hygiene, footwear, personal hygiene, and showering/bathing. The person‑centered care plan identified a communication problem related to dementia, noted that Spanish was the resident’s primary language, and stated that the resident preferred to communicate in Spanish, although she understood and spoke some English. The care plan included multiple communication interventions, including providing a translator as necessary to communicate with the resident. The resident’s History and Physical documented a language barrier and indicated that assistance was available from one of two nurses, with one able to speak Spanish. The DON reported that an interpretation document was kept at the nurse’s station on the resident’s unit. However, during interviews, CNAs assigned to care for the resident stated they were not aware of any interpreter services or interpreter services information at the facility. These staff interviews, combined with the clinical record review and the resident’s identified communication needs, showed that interpreter services were not effectively made available or known to direct care staff, resulting in a failure to implement the care‑planned intervention to provide a translator as necessary for this Spanish‑speaking resident.
Outdated Resident Rights Notices Posted and Distributed
Penalty
Summary
The facility failed to ensure the most up to date Nursing Home Resident of Rights (RBOR) was provided to each resident and displayed for residents, visitors, and staff to review. Surveyors observed that the RBOR posted at the transitional care unit entrance and outside the dining room in long term care was revised 2016, and a hanging bin by the long term care entrance contained paper copies of the RBOR dated February 2016. The facility admission packet reviewed later contained a new RBOR dated 1/1/26. During interview, social services staff stated new pamphlets were ordered in January and March and that residents admitted after those orders received the updated RBOR in their packets, but residents admitted before then had not been informed there was an update. The administrator stated they were not aware there were changes to the RBOR until locating an email from Care Providers in January identifying the update. The facility policy dated 10/22 stated residents would be provided prompt notice of changes in State or Federal laws related to resident rights or facility rules during their stay.
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