Failure to Provide Notice of Resident Rights and Services
Summary
The facility failed to provide notice of resident rights and services prior to or upon admission for all 40 residents reviewed. This deficiency was identified through interviews and record reviews conducted by the surveyor. The facility's policy requires that all residents have a signed and dated admission agreement on file, which includes a notice of rights and services. However, the surveyor found that none of the residents had a signed admission agreement at the time of admission. The surveyor's investigation revealed that the facility had transitioned from paper admission agreements to a digital CareFeed program, and it was unclear if the agreements were properly transferred. The Resident Care Coordinator (RCC) responsible for obtaining signatures admitted to the surveyor that there were issues with getting the agreements signed, especially for residents admitted after hours or on weekends. The RCC also mentioned that they had been trying to obtain signatures from residents and their families, but had not received responses. Specific cases highlighted in the report include a resident who was admitted with diagnoses such as hemiplegia, type 2 diabetes mellitus, and major depressive disorder, who did not have a signed admission agreement on file. Another resident's Power of Attorney for Healthcare was not provided with the admission agreement until the day before discharge, and the POA refused to sign it. The Nursing Home Administrator acknowledged the issue and stated that the facility was aware of the problem and working to correct it.
Penalty
Resources
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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.
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