Failure to Ensure Informed Consent for Medicare Plan Changes
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 did not ensure that residents were competent to make informed decisions about their health plan changes, nor did they provide adequate explanations of the risks involved in disenrollment, both verbally and in writing. Resident 11, who was cognitively intact with a BIMS score of 13, was disenrolled from a Medicare Advantage Plan without documented evidence of her initiating the request or understanding the implications. The facility did not assess her cognitive abilities before having her sign the disenrollment form. Similarly, Resident 16, who was moderately cognitively impaired with a BIMS score of 10, was disenrolled without involving his health care decision maker, his daughter, and without providing her with a written explanation of the risks involved. Resident 17, who was cognitively intact, was also disenrolled without documented evidence of initiating the request. Resident 21, who was moderately cognitively impaired, was disenrolled without assessing his current cognitive function or involving his responsible party, his daughter. Interviews with facility staff revealed that the facility lacked policies and procedures for assisting residents with health plan changes and failed to ensure residents' cognitive abilities were assessed before signing disenrollment forms.
Penalty
Resources
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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.
Ombudsman Contact Information Not Posted in a Visible Resident Area: The facility’s only Ombudsman Program sign was posted on a small-print sticker on a wall leading into the 200 hall and was not viewable to residents. In interviews, 4 of 6 residents did not know how to contact the ombudsman or where to find the information, and the DON and Administrator stated the posting needed to be visible, large enough to read, and at eye level. The DON also stated the facility did not have a policy regarding Ombudsman posting.
Failure to post Ombudsman and survey hotline information: Observations showed no readily available posting of the State LTC Ombudsman program or State Survey Agency hotline number in the entrances, dining room, or unit halls. In a group interview, 9 of 9 residents said they did not know where the information was located. The Administrator later stated the contact info was posted on a sheet of paper across from the elevator, and a white 8 x 11 inch sheet with several contact numbers was observed there.
Failure to Post State Complaint Information: The facility did not have State complaint filing information posted in the resident halls, nurses' stations, or main living area. In a resident council interview, residents said they had not been informed of their rights or how to formally complain to the State about the care they were receiving, and the administrator confirmed the information was not 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.
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.
Ombudsman Contact Information Not Posted in a Visible Resident Area
Penalty
Summary
The facility failed to post the Long-Term Care Ombudsman program contact information in a location available for all residents and in a format that residents could readily see and use. During observation on 05/12/2026 at 3:00 PM, the ombudsman contact information was posted on the wall leading into the 200 hallway on a white sticker with small print, and it was not viewable to residents. The posting was the facility’s single Ombudsman Program sign. In confidential interviews, 4 of 6 residents did not know how to contact the ombudsman and did not know where to find the information in the facility. On 05/14/26, the DON stated postings had to be in a visible area, large enough to see, and at eye level, and she stated the current ombudsman information might be too small for residents to see. The Administrator also stated the posting had to be easily accessible, large enough to see, and at eye level for residents in wheelchairs, and he stated the current information was potentially too small. The DON further stated the Nursing Facility did not have a policy regarding the Ombudsman posting.
Failure to Post Ombudsman and Survey Agency Contact Information
Penalty
Summary
The facility failed to provide accessible information on the location of the State Long-Term Care Ombudsman program or the State Survey Agency hotline number that was readily available to residents without assistance. With a census of 53, observations on 5/4/26, 5/5/26, 5/6/26, and 5/7/26 showed no posted information for the Ombudsman program or the State Survey Agency hotline number in the facility entrances, dining room, or halls of each unit. During a group interview on 5/6/26 at 11:30 A.M., nine out of nine residents said they did not know where the information regarding the State Long-Term Care Ombudsman program and/or the State Survey Agency hotline number was located. On 5/7/26 at 1:30 P.M., the Administrator stated the contact information was posted on a sheet of paper across from the elevator, and observation later that day showed a white 8 x 11 inch sheet of paper across from the first-floor elevator with several contact numbers listed. The Administrator also stated the Resident's Rights could have been removed from the area, but it was in the admission packet, and he would have expected the information to have been posted.
Failure to Post State Complaint Information
Penalty
Summary
The facility failed to ensure that contact information for filing a complaint with the State Agency was available to residents. During observation of both resident halls, both nurses' stations, and the main living area, there was no information posted regarding how to file a complaint with the State agency. In a confidential interview with the resident council group, residents stated they had not been informed of their rights or given information on how to formally complain to the State about the care they were receiving. The administrator also stated that the information on how to formally file a complaint with the State Agency was not posted at that time.
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.
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