Failure to Provide Mail Services on Saturdays
Summary
The facility failed to ensure residents received their mail services on Saturdays. The deficiency was identified through observations, record reviews, and interviews with residents and staff. Resident Council members reported that mail services were not provided on Saturdays, with mail only being delivered from Monday to Friday. The Activities Coordinator confirmed that there was no one available to pick up and distribute mail on Saturdays. The Administrative Nurse also stated that she handled mail delivery during weekdays but was not present on Saturdays. The facility did not provide a policy related to mail delivery, leading to the failure in ensuring residents received their mail on Saturdays.
Penalty
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The facility failed to provide a resident with reasonable access to a private telephone for communication. A resident with heart failure, depression, anxiety, and severe cognitive impairment relied on a cell phone sent by a representative, which went missing after about a week. Staff reported that, without a personal phone, residents used phones in the dining room or at the nursing station, both of which lacked privacy, and that the cordless phone was not available or not connected. This practice did not comply with the facility’s policy requiring resident access to a telephone in an area where calls could not be overheard.
Surveyors found that two cognitively intact residents reported their mail was routinely opened by the Administrator before being delivered, including business correspondence such as Social Security mail. One resident stated this happened every time such mail arrived and that she felt her privacy was violated, while another reported the Administrator opened all of her mail and then characterized much of it as junk. Admission and facility forms showed mail was to be directed to the residents and delivered unopened, and neither resident’s care plan documented any request or preference for staff to open their mail. The Social Services Director and Administrator acknowledged that the Administrator opened business mail for residents for whom the facility was representative payee, despite a written policy requiring that mail be delivered unopened and only opened by staff upon resident request documented in the care plan.
The facility failed to ensure reasonable access to and privacy in telephone communication when it removed landlines and relied on shared unit cell phones that were often unanswered or inaccessible. At times there was no receptionist to answer ringing phones, and a unit landline was nonfunctional while the unit cell phone sat unattended in the nurse’s station. The ADON and administrator stated that each floor had one cell phone for both staff and resident use and that nurses were supposed to carry it, but they could not explain staff absences from the reception desk. Family members of two residents reported repeated problems reaching staff by phone, including unanswered calls, and an RN stated that the phone system was problematic and that residents could see staff text messages and other communications about other residents when using the shared cell phone.
A resident who was cognitively able to communicate and whose assessment documented that private phone use was very important to her was routinely required to use a corded phone at the nurse’s station, an area with constant staff presence, for personal calls. Staff reported that residents without personal cell phones received calls at the front desk or nurse’s station, and one CNA stated she remained with the resident during a phone call. The resident reported that staff overheard and repeated her phone conversations, and an LVN and OT acknowledged that the resident was not afforded privacy during calls. The facility’s own resident rights policy states that residents have the right to use a telephone in privacy.
A resident did not receive an important piece of mail when staff failed to deliver an unopened letter from the local county DHS program that was later found in the facility activity area months after it was postmarked. During a complaint survey, the letter, still unopened and addressed to the discharged resident, was observed in the activity area, and the DON, when interviewed, was unable to explain why the resident had not received it.
A resident with intact cognition and multiple medical conditions posted a social media image of herself after a fall, which did not show other residents or identify the facility. Despite a stated right to privacy in electronic communications, the SSD, at the request of administration, discussed the facility’s concerns about the post and assisted in deleting it after multiple staff had approached the resident about removing it. The resident reported feeling pressured by staff to delete the post, while the DON acknowledged being present during the discussion and the Administrator stated she had asked the SSD to address the care concerns mentioned in the post but denied directing its removal.
Failure to Provide Private Telephone Access for Resident Communication
Penalty
Summary
The facility failed to ensure a resident had reasonable access to a private area for telephone communication. The resident involved had diagnoses including heart failure, depression, and anxiety, and a BIMS score of 4/15 indicating severe cognitive impairment. The resident’s representative reported sending the resident a cell phone, which went missing after about a week, and stated that the facility did not have a portable phone available for residents, making the cell phone the only option for private calls. Staff interviews confirmed that, in the absence of a resident-owned phone, residents were brought to facility phones that did not provide privacy. Multiple staff members, including LPNs and the receptionist, stated that residents could use phones located in the dining room or at the nursing station, but acknowledged these areas were not private. Staff also reported that the facility’s cordless phone was either not available or not connected, and that there was no other cordless phone for resident use. The facility’s written policy on Resident Right to Privacy in Communication required that residents be provided reasonable access to a telephone in an area where calls were not overheard, but the actual practice did not provide such a private area or functioning portable phone for the resident to make calls.
Failure to Protect Resident Privacy by Delivering Mail Already Opened
Penalty
Summary
Surveyors identified that the facility failed to ensure residents received their mail unopened and with privacy. One cognitively intact resident, identified with a BIMS score of 15, reported that the Administrator consistently gave her mail after it had already been opened, specifically noting mail from the Social Security office. She stated that this occurred every time such mail arrived, that it had been gone through, and that she felt irritated and that her privacy had been violated because she wanted to see the contents before the Administrator did. Her admission documentation indicated all incoming mail was to be directed to her, and her care plan did not address any preference or request for staff to open her mail. The Social Worker later reported that the facility was not yet her representative payee at the time these events occurred. Another cognitively intact resident, also with a BIMS score of 15, reported that the Administrator opened all of her mail before delivering it and would tell her that most of it was junk after opening it. This resident stated that having her mail opened made her feel violated. A facility form titled "Mail Release" documented that this resident had given permission for staff to deliver unopened personal and business mail, and her care plan did not address any preference or request for staff to open her mail. The Social Services Director reported that the Administrator opened mail for residents, stating she was told this was done for residents for whom the facility was representative payee. The Administrator confirmed that she opened business mail for residents when the facility was representative payee, though she said she did not open personal mail and was not aware of the specifics of the facility policy. The facility’s written policy required that residents’ mail be delivered unopened and that staff only open mail upon resident request, with such requests documented in the care plan, which was not done for these residents.
Failure to Ensure Reasonable Access to and Privacy in Telephone Communication
Penalty
Summary
The facility failed to ensure residents had reasonable access to and privacy in their use of communication methods when it eliminated landlines and relied on shared cell phones that were often unanswered or inaccessible. A paramedic reported that dispatch could not reach anyone at the facility’s cell phone after landlines were removed. On one survey day, there was no receptionist at the front desk for over 20 minutes while the phone rang unanswered, and a housekeeper confirmed there was no receptionist that day and that the previous day’s receptionist did not arrive until midday. On the second floor, the landline was nonfunctional and the unit cell phone was left inside the nurse’s station while a CNA sat outside in the hallway area. The ADON stated each floor had one cell phone for staff and resident use, that nurses were supposed to carry the phones, and that a receptionist should be present from 8:00 AM to 8:00 PM to transfer calls, but could not explain the absence of a receptionist that morning. The Administrator stated that there was always supposed to be someone at the reception desk during daytime hours to answer calls and transfer them to the unit cell phones, and confirmed that after 8:00 PM there was no one to answer the phone and callers only reached a recording with options to leave messages for various departments. He also confirmed that police, paramedics, and fire stations did not have the unit cell phone numbers and could not call them directly after hours. Family members of two residents reported repeated problems reaching staff by phone, including calls that went unanswered at night and during the day, and stated that staff did not answer the unit cell phones. An RN reported that the phone system was a problem, that families complained about calls not being answered, and that the single shared cell phone on each floor was used for staff texting with physicians and other communications that residents could see when they used the phone, exposing information about other residents. The facility’s Resident Rights policy stated that residents were to be treated with dignity, respect, and fairness while safeguarding their rights, safety, and access to services.
Failure to Ensure Resident Privacy During Telephone Use
Penalty
Summary
The deficiency involves the facility’s failure to provide privacy for residents using the telephone, resulting in staff overhearing a resident’s personal phone conversations. Resident 1’s admission record showed she was admitted on the specified date, and her MDS dated 1/20/26 documented that she had clear speech, could make herself understood, could understand others, and that it was very important to her to be able to use a phone in private. Resident 1 reported that there was no privacy when she was on the phone, stating that staff or nurses would turn around and tell other nurses what she had just said, and that staff did not seem aware that she needed privacy during calls. Observation on 3/17/26 at 2:07 p.m. showed Resident 1 in her wheelchair in the hallway using a corded phone at the nurse’s station, with multiple staff present, including an LVN sitting at the nurse’s station and an OT standing behind her while she was on the phone. Interviews with staff confirmed that residents received phone calls at the front desk or nurse’s station, areas that always had staff present. CNA 1 stated that residents received calls at these locations and that she had assisted Resident 1 to the nurse’s station phone two days prior and remained with her the entire time. The Activity Director stated that at least four residents did not have personal cell phones and needed to use the facility phone, and that Resident 1 and another resident frequently used the nurse’s station phone. LVN 1 acknowledged that Resident 1 was not provided privacy during her phone conversations and stated she needed to be in a place where no one was around or have a wireless phone in her room. OT 1 stated residents had a right to privacy while using the phone and acknowledged that being in the area while Resident 1 made a personal call invaded her privacy. The ADON stated that if privacy is invaded during a phone call, any reasonable person would be upset. The facility’s Resident Rights policy, dated August 2009, stated that residents have the right to use a telephone in privacy and to exercise their rights and privileges to the fullest extent possible.
Failure to Deliver Resident Mail from County DHS Program
Penalty
Summary
Facility staff failed to ensure a resident received mail, resulting in an unopened letter addressed to Resident #5 being found in the facility activity area. During an observation of the first-floor activity area at 2:00 p.m. on 03/04/26, surveyors observed an unopened letter addressed to Resident #5 from the local county DHS program, postmarked 10/24/25. A review of Resident #5’s closed record showed that the resident had been admitted and later discharged home, though the specific dates were not detailed in the report. When the DON was interviewed at 3:32 p.m. the same day and handed the letter, the DON stated that Resident #5 had recently been discharged and could not provide any explanation for why the resident had not received the letter when it arrived in October 2025. This deficiency was identified for 1 of 8 residents reviewed during a complaint survey and demonstrates that the facility did not ensure reasonable access to and privacy in the use of communication methods, specifically mail delivery, for Resident #5.
Failure to Protect Resident Privacy in Use of Electronic Social Media
Penalty
Summary
The facility failed to ensure a resident’s right to privacy in the use of electronic communications when staff became involved with a resident’s personal social media post. The resident, admitted with diagnoses including diabetes, cerebral infarction, major depressive disorder, hemiplegia and hemiparesis, and anxiety, had an intact cognition as evidenced by a BIMS score of 15/15. The resident posted a social media image of her own face after a fall, which did not show other residents or identify the facility by name. The facility’s Resident Rights packet, provided by the Kentucky State Long-Term Care Ombudsman Program, stated that residents have a right to privacy and confidentiality, including privacy in using electronic communications. According to a late-entry Social Service note, the Social Services Director (SSD), at the request of administration, encouraged the resident to consider removing the post and then assisted in deleting it while the resident had the post pulled up on her phone. In interview, the SSD stated she had been asked by the Administrator and Regional Nurse to speak to the resident about the post, which contained concerns about a fall, and acknowledged discussing the facility’s concerns about the post’s appearance because people knew where the resident lived. The resident reported that the SSD and other staff asked her to remove the post, that she did not know how to delete it, and that the SSD deleted it for her; she also stated she felt pressured by several staff members entering her room and asking her to remove it. The DON confirmed being present during the discussion but did not recall details and deferred to the Administrator, who stated she had asked the SSD to address the concerns about care in the post but denied instructing removal of the post and could not recall how she became aware of it or its exact content.
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