Failure to Implement Admission Policy and Disclose Service Limitations
Summary
The facility failed to implement an admission policy and did not disclose to a resident notice of special service limitations prior to admission. A resident was admitted to the facility despite being a registered sex offender, which was against the facility's admission criteria. The resident had severe cognitive impairment and multiple diagnoses, including dementia, unsteadiness on feet, repeated falls, adult failure to thrive, depression with anxiety, and Parkinson's disease. The resident was discharged shortly after admission when the facility became aware of his status as a sex offender, which was disclosed by a family member during a visit to the facility. The Director of Admissions claimed that the family did not inform him that the resident was a sex offender during the admission process. However, the family member stated that she had informed the Director and provided the contact information of the person the resident reported to. The facility's policy explicitly stated that they could not admit sex offenders, and the Director of Admissions admitted that the resident would not have been admitted if this information had been known. The situation led to the resident being discharged abruptly, causing distress to the family. Interviews with various staff members, including the Administrator, ADON, LVN, and RNC, confirmed that the facility's policy prohibited the admission of sex offenders. The Administrator and other staff members were unaware of the resident's status until it was disclosed by the family member. The facility conducted an in-service training to reinforce the admission policy and ensure that residents are checked on the relevant website prior to admission. The failure to adhere to the admission policy and the lack of proper communication led to the deficiency in the facility's admission process.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident admitted with diverticulosis and a cognitive communication deficit did not receive required admission documents at or before admission. The admissions packet was generated but later found unsigned and was only sent by certified mail after the resident had already discharged. The resident’s family confirmed the documents were received post-discharge. The Admissions Director acknowledged that some residents had not been given admission documents upon admission and that he mailed them later, citing frequent turnover in the admissions role. The DNS stated she expected admission documents to be provided timely.
Surveyors found that the facility’s admission agreement and related forms did not disclose the facility’s kosher diet practices and improperly required residents to waive certain rights and facility liability. The admission packet lacked written information about kosher dietary restrictions, and the Hospital Liaison reported that potential residents and families were not routinely informed in writing about the kosher diet, only possibly mentioned verbally without explanation. A Risk Acknowledgement form stated the facility was not responsible for stolen, lost, or damaged personal property and not responsible for the development of pressure sores, despite regulatory requirements against such waivers and requirements to provide care to prevent pressure sores. The NHA could not provide evidence that the admission agreement had been approved at the time of a change in ownership and confirmed that residents were not consistently informed in writing about the kosher diet.
The facility failed to maintain required inventories of personal belongings for two cognitively intact residents who reported missing clothing, despite a policy requiring completion and updating of inventory sheets and staff acknowledgment that such forms should be present and scanned into the medical record. A resident with anxiety, DM, and glaucoma did not receive an admission packet on the day of admission and lacked a baseline care plan, with the admission packet only signed later. The facility also used a new admission agreement that did not address prior $6,000 security deposits required under a previous management contract; one resident’s family provided documentation of having paid such a deposit, but subsequent invoices showed no record of a refund after discharge, while leadership reported unawareness of the prior deposit terms and that deposit funds were not turned over during the ownership change.
A resident with DM and HTN, who required supervision to maximal assistance with ADLs, was admitted without obtaining admission consent from the court-appointed conservator, despite facility policy requiring consent from the resident or responsible party and presentation of surrogate documentation at or before admission. The conservator later reported she had not been informed of the transfer and had not authorized the admission, and the Admission Coordinator acknowledged that the facility’s admission policy was not followed.
A resident was readmitted with an order for IV Zosyn to treat an abdominal infection, but the facility did not have the medication available and could not obtain it from their contracted after-hours pharmacy. This resulted in delayed treatment and the resident being transferred to another facility for care.
The facility did not complete admission agreements in a timely manner for three residents, with delays ranging from three to nine days after admission due to unavailability of responsible parties. In each case, the required paperwork, which included consent for treatment and payment information, was not signed at the time of admission, and the facility relied on implied consent until signatures could be obtained. No policy or procedure was available to guide staff in these situations.
Failure to Provide Admission Documents at or Before Admission
Penalty
Summary
The facility failed to ensure that a resident received required admission documents at or before admission, as required for resident rights and understanding of services. One resident admitted in October 2025 with diagnoses including diverticulosis and a cognitive communication deficit did not receive the admission packet at the time of admission. A certified mail receipt dated February 6, 2026, with a handwritten note showed that the admissions packet had originally been generated on October 30, 2025, but it was later discovered that it was not signed. The packet was subsequently sent to the resident by certified mail, and the resident’s family member confirmed that the admission documents were not received until after the resident had discharged from the facility. The Admissions Director stated he noticed that some residents had not received their admission documents upon admission and that he mailed the documents to those residents, also noting that many staff had been in the admissions position and some had been terminated or had quit. The DNS stated she expected staff to provide residents their admission documents in a timely manner.
Noncompliant Admission Agreement and Failure to Disclose Kosher Diet Requirements
Penalty
Summary
The deficiency involves the facility’s admission agreement and related documents failing to disclose special service limitations related to the facility’s kosher diet and improperly requiring residents to waive certain rights and facility liability. Record review of the admission packet showed that the Admission Agreement did not contain information about the facility’s kosher dietary practices, despite the facility following a kosher diet. A separate welcome packet included an “Always Available Menu” listing items such as tuna salad, egg salad, turkey, bologna, and pastrami sandwiches, with a note that any alternate chosen must reflect a kosher-appropriate option (dairy for dairy meal, meat for meat meal), but there was no other mention of special dietary considerations. The Hospital Liaison, who speaks with potential residents in the hospital, stated that residents and families are not informed in writing prior to admission that the facility follows a kosher diet, and that she may only casually mention it without explaining what it means unless specifically asked. Further review of the admission documents revealed that the Admission Agreement required the resident and sponsor to agree not to hold the facility responsible for injury or harm that could have been avoided if they had hired a private duty nurse. A separate Risk Acknowledgement form stated that the facility was not responsible for stolen, lost, or damaged personal property and was not responsible for the development of pressure sores, despite regulatory requirements prohibiting waiver of potential facility liability for personal property losses and requiring the facility to provide quality care, including treatment and services to prevent pressure sores. When requested, the NHA was unable to provide proof that the admission agreement had been approved at the time of the change in ownership in 2017 and confirmed that residents were not informed in writing prior to admission that the facility followed a kosher diet. The NHA could not verify that any brochure describing the kosher diet was consistently provided to residents and offered no rationale for the noncompliant admission agreement and risk acknowledgement language.
Failure to Maintain Personal Property Inventories and Provide Accurate Admission and Deposit Information
Penalty
Summary
The deficiency involves the facility’s failure to maintain and update residents’ personal belongings inventories and to follow its grievance and missing property policy, as well as failures related to admission information and financial agreements. The facility’s policy dated 7/1/25 stated that residents and representatives have the right to report missing items, that staff may resolve grievances immediately or follow the grievance procedure if unable to do so, and that supervisory personnel are responsible for notifying residents and representatives of the outcome of missing property investigations. For one cognitively intact resident admitted on 6/3/25 with diagnoses including arthritis and spinal stenosis, there was no inventory of personal belongings sheet in the medical record despite observation of multiple personal items in the room. This resident reported missing specific clothing items, stated they had informed multiple staff members, and reported that no one followed up and that they had never been provided an inventory sheet at admission or afterward. Another cognitively intact resident admitted on 4/27/25 with diagnoses including heart failure, hip fracture, diabetes, and kidney disease also had no inventory sheet in the record, despite having numerous clothing items in the room, and reported multiple tops missing after being sent to laundry, stating they had never completed an inventory of personal belongings. Staff interviews confirmed that the facility’s process required inventory sheets to be completed on admission and updated when new items were brought in, with forms to be scanned into the medical record. A CMT stated that paper inventory sheets were available on each hall and should be completed and updated, and the Laundry Supervisor stated that an inventory sheet should exist for every resident and be located either in the medical record or in the resident’s room. The Laundry Supervisor reported not having seen inventory sheets for the two residents with missing clothing and being unable to locate their missing items. The Administrator and DON stated they expected staff to complete inventory sheets on admission and update them when new items arrived, and that staff should attempt to locate missing clothing and initiate an investigation if items were not found. Additional deficiencies involved admission information and financial agreements. One resident admitted on 1/5/26 with diagnoses including anxiety, diabetes, and open angle glaucoma did not have a baseline care plan in the record and reported not receiving a welcome/admission packet on admission; the admission packet on file was signed by the resident on 1/23/26, indicating it was not provided on the day of admission as expected by the Administrator. The facility’s prior admission agreement under the previous management company required a $6,000 interest-free security deposit, refundable within 45 days after discharge, and described how it would be treated for Medicaid and room-and-board charges. The current admission agreement under new management did not address the prior contract or deposits made under it. For a resident with severe cognitive impairment and multiple diagnoses including hypertension, non-Alzheimer’s dementia, and asthma, documentation from the family showed a $6,000 deposit paid at application along with room and board charges, and progress notes documented the resident’s transfer and discharge; however, invoices reviewed later showed no documentation of a refund of the $6,000 deposit. Interviews with the Regional Nurse Consultant and Administrator revealed unawareness of the prior deposit requirement, lack of documentation addressing previous deposits in the new agreement, and that funds related to deposits were not turned over during the ownership change, while the facility was still operating under the previous management company and honoring the original contract.
Failure to Obtain Required Admission Consent From Resident’s Conservator
Penalty
Summary
The deficiency involves the facility’s failure to obtain admission consent in accordance with its policy and procedure titled “admission to the Facility.” One resident was admitted on a specified date with diagnoses including diabetes mellitus and hypertension. The resident’s History and Physical dated 12/12/2025 documented that the resident did not have the capacity to understand and make decisions, while the MDS dated 12/14/2025 indicated the resident was able to understand and be understood by others and required varying levels of assistance with ADLs, including supervision, moderate assistance, and maximal assistance for mobility and self-care tasks. Despite the resident’s documented need for assistance and questions about decision-making capacity, the facility proceeded with admission without obtaining consent from the resident or the responsible party. During an interview, the resident’s family member stated she was the court-appointed conservator and reported that the prior facility did not inform her that the resident was being transferred and that she did not give the admitting facility permission to take the resident. In a concurrent interview and record review, the Admission Coordinator acknowledged that the facility’s policy was not followed when the conservator’s consent was not obtained prior to admission and stated that the conservator’s admission consent should have been obtained to ensure the resident’s and conservator’s wishes were respected. Review of the facility’s admission policy dated 1/2023 showed that residents are to be admitted only upon written order of the attending physician and with the consent of the resident or responsible party, and that identifying paperwork for any appointed surrogate or representative must be presented prior to or upon admission. These requirements were not met in this case.
Failure to Provide Ordered IV Antibiotic Upon Readmission
Penalty
Summary
The facility failed to provide necessary treatment for a resident who was readmitted with an order for intravenous (IV) Zosyn, an antibiotic required for an abdominal infection following acute appendicitis with abscess. The hospital had communicated the need for IV Zosyn prior to the resident's transfer, and the facility staff, including the RN Case Manager and Director of Nursing, were aware of the requirement. However, upon the resident's arrival, the facility did not have IV Zosyn available, and the in-house pharmacy was closed. Attempts to obtain the medication from the contracted after-hours IV pharmacy were unsuccessful, as the pharmacy was not open during the weekend hours. The facility's process for reviewing new admissions or readmissions included determining whether the facility could meet the resident's care needs. Despite this, the staff did not verify the availability of IV Zosyn before accepting the resident for readmission. The emergency medication kit did not contain IV Zosyn, and the pharmacy manager was not informed in advance about the need for this medication. The facility's after-hours pharmacy contract indicated that emergency or expedited orders could be delivered on weekends and holidays upon mutual agreement, but this process was not successfully executed in this case. As a result of the facility's inability to provide the ordered IV antibiotic, the resident experienced a delay in receiving necessary medication and was subsequently transferred to another facility that could provide the required treatment. The failure to ensure medication availability prior to readmission directly led to the deficiency identified in the report.
Failure to Timely Complete Admission Agreements
Penalty
Summary
The facility failed to complete admission agreements in a timely manner for three residents. For one resident, the admission agreement paperwork was signed four days after admission, despite the resident being able to sign the paperwork herself. In another case, the admission agreement was signed three days after admission by the resident's daughter and Power of Attorney, and the resident herself signed the agreement several weeks later. For the third resident, the admission agreement was signed nine days after admission due to the unavailability of the resident's wife, who was ill and unable to attend the planned meeting until later. Interviews with the Executive Director revealed that in cases where responsible parties were unavailable, the facility relied on implied consent until the admission agreement could be completed. The facility did not have a policy or procedure available regarding the handling of admission agreements when responsible parties were not immediately available. The admission agreements included important information such as resident obligations, consent for treatment, payment details, and other required disclosures.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
