Failure to Inform Resident of Their Rights
Summary
The facility failed to ensure that a resident was informed of their rights during their stay. The resident, who was admitted with a fracture of the left patella, stated during an interview that she was curious about her rights and had not been provided a copy of them. An interview with an LPN revealed that the admission packet reviewed by the nurse did not include a copy of the resident rights. Further investigation showed that the facility had two admission packets, one clinical and one non-clinical, with the latter containing the resident rights information. However, due to the absence of a ward clerk, the non-clinical packet had not been completed for some time, and no one had been providing residents with a copy of their rights during this period. The Director of Nursing and Assistant Director of Nursing confirmed that the responsibility of providing the resident rights form did not fall on the nurses and acknowledged the lapse in the process due to the lack of a ward clerk. The facility's policy included in the admission packet mandates a copy of the patient's rights along with an acknowledgment of receipt. Despite this policy, the absence of a ward clerk led to a failure in providing residents with their rights information. The new ward clerk was still in training, and the process of completing the second admission packet had not resumed. This deficiency highlights a significant gap in the facility's admission process, potentially leaving residents uninformed about their rights and unable to advocate for themselves effectively.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility did not review Resident Rights during Resident Council meetings for several months, as confirmed by resident and staff interviews and review of meeting minutes. Multiple residents who attended these meetings were unaware of where to find information about their rights, and the omission was attributed to a change in agenda forms by the Activities Director.
The facility did not provide ongoing communication about resident rights during Resident Council meetings, as confirmed by a review of meeting minutes and interviews with a resident and the Activity Director. This omission had the potential to affect all residents in the facility.
Failure to Review Resident Rights During Resident Council Meetings
Penalty
Summary
The facility failed to ensure that residents were informed of their Resident Rights, as required by policy. Review of Resident Council meeting minutes over an 11-month period showed that Resident Rights were not discussed during these meetings. Interviews with several residents confirmed that they were not aware of where to find information about their rights and that these rights had not been reviewed during Resident Council sessions. The Activities Director acknowledged that Resident Rights were omitted from the meetings due to a change in the agenda forms. Facility policy indicated that Resident Rights should be reviewed during Resident Council meetings, but this was not done, affecting multiple residents who attended these meetings.
Failure to Communicate Resident Rights During Council Meetings
Penalty
Summary
The facility failed to provide ongoing communication to residents regarding their rights, as evidenced by a review of Resident Council meeting minutes over a period of several months, which showed no documentation of resident rights being discussed. An interview with a resident confirmed that staff did not review resident rights during Resident Council meetings. Additionally, the Activity Director, who had been conducting the meetings since September 2024, acknowledged that she was not discussing resident rights with residents and only became aware of the requirement to do so in March 2025. This lack of communication regarding resident rights had the potential to affect all residents in the facility, which had a census of 44 at the time of the survey.
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.
