Failure to Ensure Informed Consent for Medicare Disenrollment
Summary
The facility failed to develop and implement policies and procedures to protect residents from being disenrolled from their Medicare health plans without their informed consent. This deficiency was identified through a review of clinical records, CMS guidance, facility documentation, and staff interviews. The facility disenrolled seven residents from their Medicare Advantage plans without ensuring that the residents or their representatives fully understood the implications of such changes. The residents affected included those with various medical conditions such as diabetes, bipolar disorder, cognitive communication deficits, and dementia. The review revealed that the facility's Business Office Manager (BOM) had discussions with residents about transitioning to traditional Medicare, citing potential benefits such as increased therapy time and reduced need for authorizations. However, there was no evidence that the residents were provided with written and verbal explanations of the risks associated with disenrollment, nor was there documentation of the residents' cognitive ability to understand these changes. In some cases, the residents were noted to be cognitively intact, while others had moderate cognitive impairments, raising concerns about their capacity to make informed decisions. Interviews with the Nursing Home Administrator and BOM confirmed that the facility lacked policies and procedures for assisting residents with Medicare plan changes. This oversight led to the facility initiating changes in Medicare health plans without proper documentation of the residents' requests or consent. The deficiency was cited as past non-compliance, indicating that the facility had not adhered to CMS guidelines and resident rights regarding Medicare health plan enrollment and disenrollment.
Penalty
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A facility failed to ensure the current RBOR was posted for residents, visitors, and staff to review. One RBOR poster in a locked glass case had no print date, and another posted near the therapy room was dated 11/16. The DON stated she was unaware of changes to the RBOR form and did not know the updated version needed to be obtained and posted.
Facility staff did not ensure that residents knew where to find the list of contact names, addresses, and phone numbers for the ombudsman, adult protective services, and other State agencies. In a resident group meeting with the Resident Council President and four other residents, all five reported they did not know how to contact these agencies. The Activities Director later stated that residents are educated at each resident council meeting about the ombudsman and the location of the contact information, and that this is documented in council minutes. When these findings were presented to the Interim Administrator, DON, ADON, and Corporate Nurse Consultant, they did not offer comments or concerns.
Failure to Inform Residents of Complaint Rights: The facility did not inform residents of their right to file a complaint with the State survey and certification agency. The ADM stated there were no Resident Council meetings for two months due to lack of a president, and the only available council minutes did not show that residents’ rights were reviewed. During the survey, multiple residents said no information was shared about complaint rights and they did not know where the information was posted.
Missing Resident Rights and Complaint Posting Information: The facility did not have the required postings available for residents on how to file complaints with the State Survey Agency, how to file grievances, or how to access residents’ rights information. During a Resident Council meeting, several residents stated they did not know how to file a complaint or grievance and had no access to the required information. The NHA said the postings should have been on the wall near the nurses’ station and on the SSC’s door, but the surveyor could not find them, and the posted state agency map did not include contact information.
Ombudsman contact information was not posted for public view in the facility. A resident reported trying to reach the ombudsman and said he only had the prior ombudsman’s contact information, while front desk staff stated the updated information was taped on her side of the desk rather than posted where residents and visitors could see it.
Missing State Survey Agency Posting: The facility failed to display the State Survey Agency phone number and contact information in prominent, readily accessible locations on two nursing units. During a tour, the DOSS was unsure where the postings were located, and the required complaint/reporting information could not be found in the nursing units or common areas. The NHA later confirmed the postings were not up and may have been removed during painting.
Outdated Resident Rights Posting
Penalty
Summary
The facility failed to ensure the most up to date Nursing Home Resident Rights (RBOR) was displayed for residents, visitors, and staff to review. During observation, the RBOR poster was seen in a locked glass case near the main entrance and elevators without a print date, and a combined RBOR posted near the therapy room entrance in the main lobby was dated 11/16. During interview, the administrator stated she was unaware of any changes to the RBOR form and did not know the updated version needed to be obtained and posted. The facility policy, revised 12/23/25, required resident rights and other required information to be posted in a visible, accessible location and kept updated at all times.
Residents Unaware of How to Access Ombudsman and State Agency Contact Information
Penalty
Summary
Facility staff failed to ensure that residents knew the location of the list of contact names, addresses, and phone numbers for State agencies, the ombudsman, and adult protective services, resulting in 5 of 5 residents attending a resident group meeting being unaware of how to contact these entities. During a resident group meeting held with the Resident Council President and four regularly attending residents, all participants reported they did not know how to contact the ombudsman, adult protective services, or other state offices. A subsequent interview with the Activities Director revealed that she stated residents are educated at every resident council meeting about the ombudsman and where to find the contact information, and that this education is documented in the resident council minutes. In a final interview with the Interim Administrator, DON, ADON, and Corporate Nurse Consultant, the surveyor conveyed these findings, and the administrative team made no comments and voiced no concerns. No additional medical history or clinical conditions of the residents were provided in the report, and the deficiency centers on residents’ lack of awareness of how to access posted or available contact information for external advocacy and protective agencies.
Failure to Inform Residents of Complaint Rights
Penalty
Summary
The facility failed to inform residents of their right to file a complaint with the State survey and certification agency. During an interview, the Administrator stated there were no Resident Council meetings held in February 2026 and March 2026 because there was no president for the meetings, and only one month of council meeting minutes dated 01/28/26 was available. The Administrator also stated there was no evidence that residents’ rights to file a complaint with the State survey and certification agency were discussed at the January 2026 Resident Council meeting. During the annual survey resident council interview, Residents #11, #15, and #38 stated there was no information shared or discussed regarding their right to file a complaint with the State survey and certification agency, and they said they had no knowledge of where that information was posted in the facility. Review of the available January 2026 Resident Council meeting minutes showed no evidence that residents’ rights were reviewed during the meeting, and no additional Resident Council meeting minutes were available for review.
Missing Resident Rights and Complaint Posting Information
Penalty
Summary
The facility did not ensure residents were given information in a format and language they could understand about how to file a complaint, including the name and contact information for the State Survey Agency and a list of names, addresses, and telephone numbers of other pertinent state agencies. The facility also did not ensure information about residents’ rights and how to file a grievance was posted in the building. During an environmental tour on 4/6/26, the surveyor could not locate the required postings on how to file a complaint with the State Agency, access a list of state agencies, file a grievance with the facility, or review residents’ rights. During a Resident Council meeting on 4/7/26, R39, R55, R18, R45, and R46 stated they did not know how to file a complaint with the State Agency, did not know how to access a list of state agencies, did not know how to file a grievance with the facility, and did not have access to information regarding residents’ rights. R39’s MDS dated 1/23/26 showed moderately impaired cognition, R18’s MDS dated 3/23/26 showed moderately impaired cognition, R45’s MDS dated 4/7/26 showed intact cognition, and R46’s MDS dated 4/13/26 showed intact cognition; R55’s record did not contain cognition information. The NHA stated the required postings were supposed to be on the wall across from the nurses’ station and on the SSC’s door, but the surveyor did not observe them there. The surveyor observed only an Ombudsman posting on the SSC’s door, and the SSC stated awareness of the required postings was lacking. On 4/8/26, the NHA said a map of state agencies was posted, but it did not include contact information, and the NHA could not locate the required postings containing State Agency contact information, grievance information, and residents’ rights.
Ombudsman Contact Information Not Posted
Penalty
Summary
The facility failed to post the State Long-Term Care Ombudsman's contact information. During a Resident Council meeting, a resident stated he had been trying to contact the ombudsman and wanted them to attend a resident council meeting, but he only had the contact information for the previous area ombudsman and was not aware there was a new ombudsman. He also stated there was no ombudsman information posted in the facility. Later that day, no ombudsman information was observed at the front desk, and front desk staff stated she had the ombudsman information taped on her side of the desk, but it was not posted for public view. The finding was discussed with the Regional Nurse Consultant, and no additional information was received.
Missing State Survey Agency Posting
Penalty
Summary
The facility failed to post the State Survey Agency phone number and contact information in readily accessible locations on two nursing floors, including the 1st Floor and 2nd Nursing Units. During a tour with the Director of Social Services, the employee stated she was new to the facility and was unsure where the State Survey Agency postings were located. A review of the nursing units and common areas did not locate the required State Survey Agency phone number, contact information, or reporting information. The Nursing Home Administrator later confirmed that the required postings were not up and may have been taken down during painting. The report states that the facility did not ensure the required postings, including the name, address, and telephone number for the State Survey Agency, were displayed in prominent places throughout the facility, along with a statement that residents may file a complaint with the State Survey Agency regarding abuse, neglect, exploitation, or misappropriation of resident property.
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