Failure to Address Communication Deficits in Resident Care Plan
Summary
The facility failed to ensure that a resident with communication deficits had appropriate interventions to accommodate their needs and abilities. The resident, who was admitted with diagnoses including cerebral infarction, hemiplegia, and dysarthria, had impaired cognition and speech intelligibility issues. Despite these challenges, the resident's care plan did not adequately address the communication barriers, as evidenced by the lack of communication devices like a whiteboard in the resident's room and inconsistent staff awareness of the resident's communication needs. Observations and interviews revealed that the resident had significant difficulty being understood due to slurred speech and hearing impairment. Staff members, including a CNA and a speech therapist, noted the resident's challenges in communication, yet there was no consistent use of recommended communication aids such as a whiteboard. The speech therapist had informed nursing staff about the need for such aids, but this was not reflected in the care plan or consistently implemented in practice. Interviews with facility staff, including the Director of Nursing and the MDS coordinator, highlighted discrepancies in the assessment and documentation of the resident's communication abilities. The MDS assessment inaccurately coded the resident's speech as clear, despite evidence to the contrary. The lack of a comprehensive care plan addressing the resident's communication deficits posed a risk of miscommunication, potentially affecting the resident's ability to express needs and preferences effectively.
Penalty
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Failure to Deliver Resident Mail on Saturdays: Residents reported during Resident Council that mail delivered by the post office on Saturdays was not given to them until Monday. The DON stated mail should be delivered the same day it arrived and that timely mail delivery was a resident right, but she could not identify a specific staff member responsible for overseeing the process. The Admin also stated all staff were responsible for delivering mail, including on weekends, and that mail should be delivered the same day it arrived.
The facility failed to ensure residents received their mail in a timely manner, particularly mail delivered on Saturdays. During a council meeting, several residents reported that Saturday mail was not brought to them until Monday. The new Activity Director did not work weekends and was unfamiliar with the weekend mail process. The weekday receptionist stated that the weekend receptionist had no key to the outdoor mailbox, so mail was not retrieved on Saturdays unless the Business Office Manager was present. The Business Office Manager confirmed that when she was absent on weekends, no one else could access or deliver residents’ mail, and that after the prior Activity Director left, there was no designated staff to deliver weekend mail, resulting in periods when residents did not receive their mail on the day it arrived.
No Accessible Phone Available for Resident Use: A resident with intact cognition, quadriplegia, and dependence for all ADLs did not have access to a phone for communication. Observation showed no accessible phones available, and the Administrator and RDO confirmed the facility’s resident-use phones were not accessible to the resident, so staff had been using personal cell phones to help him make calls.
Resident mail was not delivered on Saturdays for four residents who raised the issue during Resident Council. Residents reported that Saturday mail was left at the front desk and not sorted and delivered until Monday, while the secretary said she handled mail Monday through Friday and the weekend nursing supervisor was responsible. An RN said she was unaware weekend mail delivery was part of her duties and did not have time to do it when she was the only nurse in the building. The Administrator stated weekend mail was typically delivered Monday, despite the facility policy requiring mail delivery six days a week.
Residents did not receive mail delivery on Saturdays. During Resident Council, residents reported the issue, and the Activity Director confirmed that mail was not delivered on Saturdays. The Administrator stated that the manager on duty would get and deliver the mail going forward.
A resident with multiple chronic conditions, who relied on phone contact with a seriously ill significant other, lost access to private communication after her personal cell phone was broken and sent out for repair. Facility policy guarantees residents access to a telephone and private communication, but there was no cordless phone available on the relevant hall, and staff, including the DON, SSD, and Administrator, confirmed there was no convenient method for residents on that hall to make private calls without arranging to use a staff office. This resulted in the resident having no readily available, private telephone option.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
The facility failed to ensure residents had reasonable access to and privacy in their use of communication methods when resident mail was not delivered to residents on Saturdays for 4 of 4 residents who raised the concern during Resident Council. During the meeting, residents stated that mail delivered by the post office on Saturdays was not given to residents until Monday. The DON stated mail was sorted when it came into the building and should be delivered the same day by facility staff, that it was the responsibility of all staff to ensure residents received their mail, and that timely mail delivery was a resident right; however, she could not identify a specific staff member responsible for overseeing mail delivery. The Administrator also stated that all staff were responsible for delivering mail to residents, including on weekends, and that mail should be delivered the same day it arrived at the facility. A policy was requested but not provided.
Failure to Ensure Timely Weekend Mail Delivery to Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents’ right to receive mail, including mail delivered on Saturdays. During a Resident Council group interview, several residents reported that when mail was delivered to the facility on Saturdays, it was not distributed to them until Monday by the Activity Director. Multiple residents agreed with this account, and no residents present disagreed. The new Activity Director, who had transitioned from working as a Certified Occupational Therapist Assistant on 04/24/26, stated she did not work weekends and was unsure how mail delivery to residents was handled on weekends. Staff interviews further showed that the weekend receptionist did not have a key to the outdoor mailbox and therefore could not retrieve Saturday mail. The weekday Receptionist reported that she collected the mail from the outdoor mailbox on Monday mornings and gave it to the Business Office Manager, after which the Activity Director delivered it to residents. The Business Office Manager confirmed that if she was not at work on weekends, no one else had access to the outdoor mailbox. She stated she worked most Saturdays, checked and sorted the mail, and then gave residents’ mail to activity staff or delivered it herself, but noted that after the previous Activity Director left 6–7 weeks earlier, there was no one designated to deliver mail to residents on weekends when she was not present. The Administrator acknowledged that there were approximately three weeks when weekend mail was not delivered to residents due to turnover in the activity department and the absence of an Activity Director.
No Accessible Phone Available for Resident Use
Penalty
Summary
The facility failed to ensure residents had reasonable access to and privacy in their use of communication methods by not having a phone available for resident use. This affected one resident reviewed for telephone communication out of three reviewed, in a facility census of 52 residents. The resident had an admission date of 03/08/26 and diagnoses including kidney stones, quadriplegia, and depression, with a discharge date of 03/12/26. The MDS dated 03/12/26 showed the resident had intact cognition and was dependent on staff for all ADLs. During observation on 05/04/26 at 11:58 A.M., no phones were accessible for the resident. The Administrator confirmed at 12:00 P.M. that the resident did not tolerate getting out of bed due to his medical condition and that the phones provided for resident use were not accessible to him. The RDO confirmed at 12:02 P.M. that the facility did not have an accessible phone for the resident’s use and stated staff had been using their personal cell phones to help the resident make calls.
Resident mail not delivered on Saturdays
Penalty
Summary
The facility failed to ensure resident mail was delivered to residents on Saturdays for four residents who raised the concern during Resident Council. During the 4/30/26 Resident Council meeting, R24 stated that mail delivered by the post office on Saturdays was left on the receptionist's desk near the front entrance and then sorted and delivered by the receptionist on Monday morning. R33, R34, and R14 confirmed that Saturday mail was not delivered to residents. During interviews, the secretary stated that she sorted and delivered mail Monday through Friday, and that weekend mail delivery was the responsibility of the nursing supervisor. An RN stated she was unaware that collecting and passing mail was part of her weekend responsibilities and said she did not have time to deliver mail when she was the only nurse in the building overseeing all staff and residents. The Administrator stated it was the responsibility of the secretary at the front desk to deliver mail and acknowledged that mail delivered over the weekend was typically delivered Monday after front desk staff arrived, although her expectation was that mail would be delivered the same day it was delivered to the facility. The facility policy stated resident mail was to be delivered six days a week, Monday through Saturday, in a timely fashion.
Failure to Deliver Resident Mail on Saturdays
Penalty
Summary
Residents did not have access to mail delivery on Saturdays, despite the facility’s obligation to ensure residents have reasonable access to and privacy in their use of communication methods. During the Resident Council meeting on 04/28/26 at 3:30 PM, residents stated that they do not receive their mail delivery on Saturdays. On 04/29/26 at 9:00 AM, the Activity Director verified that residents do not receive mail on Saturdays. On 04/29/26 at 9:25 AM, the Administrator stated that the manager on duty will get the mail and deliver it to the residents from now on. Residents identified in the report included #55, #20, #10, #33, #50, #39, #22, #45, #24, and #30, with a facility census of 60.
Failure to Ensure Resident Access to Private Telephone Communication
Penalty
Summary
The facility failed to ensure a resident’s right to reasonable access to and privacy in the use of a telephone for communication. Facility policy on Resident Rights, revised December 2016, states that residents are guaranteed access to a telephone, mail, and email, and the ability to communicate in person and by mail, email, and telephone with privacy. Resident #1 was admitted on 12/18/24 with diagnoses including Sjogren syndrome, rheumatoid arthritis, chronic kidney disease, and morbid obesity. During an interview, the resident reported that she had dropped and broken her personal cellular telephone, which she had used for private communication, and that the facility did not have any telephone that was convenient for her to use privately. She stated that no staff had offered her the use of a staff office or any other mechanism for private communication, and she was upset because she relied on telephone contact with her significant other, who had cancer and was unable to visit. Observations and staff interviews confirmed the lack of accessible, private telephone options for residents on South Hall. An observation on the 100 Hall revealed there was no cordless telephone available for resident use. The DON confirmed that the facility did not have a method to provide residents on South Hall with private communication without first making arrangements or an appointment to use a staff office, and that the cordless telephones in the facility did not have sufficient range to reach South Hall. The SSD confirmed there were no cordless telephones at the South Hall nurses’ station that could be taken to residents’ rooms and acknowledged that Resident #1’s cell phone had been broken and sent out for repair. The Administrator also confirmed that residents on South Hall did not have a method for private communication without prior arrangements and acknowledged that access to private communication is a guaranteed resident right.
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