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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Staff failed to ensure residents knew where to find contact information for the State Survey Agency and the State LTC Ombudsman. Required lists of names, mailing/email addresses, and phone numbers were posted behind the concierge desk in an area not accessible to residents, and no other signage was present on the unit. During a Resident Council meeting, all residents present were unable to identify the location of this information and were unaware of their right to file complaints with the State or Ombudsman. Later, two residents taken to see the posting stated they had not known it was there, while the concierge reported residents must ask for the information and that none had done so during her tenure.
The facility failed to post required information informing residents how to formally complain to the State Agency. During a resident council meeting, residents reported they did not know how to make a formal complaint to the state, and a subsequent tour showed that the main bulletin board for residents and visitors did not include instructions for filing a complaint with the state agency. The NHA later confirmed the absence of this required complaint information, which was reviewed with the NHA, DON, and a corporate nurse during the survey exit conference.
The facility did not ensure that residents were informed of their right to file a complaint with the State Survey Agency, and failed to provide visible, readable, and accurate contact information. Multiple residents were unaware of where to find this information, and both the AD and DON confirmed that the posted details were not accessible or correct, contrary to facility policy.
The facility did not ensure that residents were informed about how to contact the State Long-Term Care Ombudsman or file complaints with the State Survey Agency. Residents reported not knowing how to access these resources, and required information was missing from admission packets and not discussed during resident council meetings. Staff interviews confirmed that this information was not routinely provided or documented.
Surveyors found that the facility did not have the State Ombudsman contact information posted and accessible for residents and visitors. During a tour with the DON and an administrator, it was confirmed that the information was missing and that there was no facility policy for posting advocacy numbers, potentially affecting all residents.
Four cognitively intact residents, each requiring assistance with ADLs due to various medical conditions, were not provided with written notices or contact information for advocacy groups or instructions on filing complaints with the State Agency. Residents were unaware of the Long-Term Care Ombudsman and reporting procedures, and staff only referenced a poster at the entrance rather than directly informing residents, contrary to facility policy.
Failure to Inform Residents of Location of State and Ombudsman Contact Information
Penalty
Summary
Facility staff failed to ensure that residents were informed of the location of contact information for the State Survey Agency and the State Long-Term Care Ombudsman program. During an observation of the third floor, the required list of names, mailing and email addresses, and telephone numbers for the State licensure office and the State Long-Term Care Ombudsman was found posted behind the concierge’s desk on the wall, in a location inaccessible to residents. No other signage with this required information was posted on the third floor. At a Resident Council meeting, all 10 residents present were unable to identify where the contact information for the State licensure office and the State Long-Term Care Ombudsman was located and were unaware of their right to file a complaint with these entities. After the meeting, the Activities Director escorted two residents to view the Ombudsman information, and both stated they did not know it was posted there. Concierge staff reported that residents must ask for the information and phone numbers if they need them and that no resident had requested this information during the five years she had worked at the facility. The Activities Director reported there was another copy of the information outside her office on the second floor for assisted living residents. Leadership, including the DON, ADON, and Administrator, were later informed of these findings.
Failure to Post Information on How to File State Agency Complaints
Penalty
Summary
The facility failed to ensure that information on how residents can formally complain to the State Agency was displayed in a format and language residents understood. During a resident council meeting on 9/24/25 at 1:45 PM, all residents in attendance denied knowing how to make a formal complaint to the state of Delaware. Later that day at 2:08 PM, during a tour of the facility to check required postings, the surveyor observed that the first-floor bulletin case, which displayed information for residents and visitors, did not include information on how to make a complaint to the state agency. At 2:27 PM, the Nursing Home Administrator (E1) confirmed this finding. On 9/29/25 at 1:25 PM, the same finding regarding the lack of posted information about how to file a complaint with the state agency was reviewed with the NHA (E1), the DON (E2), and the Corporate Nurse (E3) during the exit conference.
Failure to Provide Accessible and Accurate State Survey Agency Contact Information
Penalty
Summary
The facility failed to ensure that residents were properly informed of their right to file a complaint with the State Survey Agency, and did not provide visible, readable, and accurate contact information for the agency. During a Resident Council meeting, four out of five residents stated they did not know where the State Survey Agency contact information was posted and had not been made aware of where to find it. Observations confirmed that the required contact information was either missing or posted in a manner that was not easily readable, with incorrect address and telephone number details. The Activity Director acknowledged that the information was not accessible or accurate, and that it should have been provided during monthly council meetings. Further observation with the DON confirmed that the posted contact information was not visible, easily readable, or up to date, and that the residents' right to file a complaint with the State was not honored. Review of the facility's policy and procedure indicated that residents are to be informed about their rights, including the right to communicate with outside agencies. The deficiency was identified through direct observation, resident interviews, and review of facility policy.
Failure to Provide Residents with Advocacy and Complaint Information
Penalty
Summary
The facility failed to ensure that residents received information and contact details for State and local advocacy organizations, including the State Survey Agency and the State Long-Term Care Ombudsman program, in a language and format they understood. Record review of monthly resident council minutes for the past six months showed no documentation of discussions regarding how to file a complaint with the state agency or review of ombudsman information. During a confidential group meeting, all seven residents present stated they did not know how to contact the ombudsman or file a complaint with the state agency, although they recalled being given a brief overview of the program and the ombudsman's name. The facility's admission packet was found to lack the required grievance procedure section and did not include state agency or ombudsman contact numbers. Interviews with the Administrator and Activities Director revealed that while residents were told they could file grievances with facility staff, information about filing complaints directly with the state or contacting the ombudsman was not routinely provided or documented. The Administrator stated that state and ombudsman information was only given if specifically requested by residents or families, and the Activities Director confirmed that the process for contacting the state agency was not explained or documented during resident council meetings. Although ombudsman information was posted at the facility entrance, residents were not consistently informed about their rights or the procedures for filing complaints with external agencies.
Ombudsman Contact Information Not Posted
Penalty
Summary
The facility failed to ensure that the name and contact information for the State Long Term Care Ombudsman was posted and readily available for residents and visitors. During a tour of the skilled areas and nursing home units, surveyors observed that the required Ombudsman information was not posted. The Director of Nursing and an administrator confirmed during the tour that the information was not available and acknowledged it should have been accessible to residents. Additionally, the administrator stated in an interview that the facility did not have a policy regarding the posting of resident advocacy numbers, although they followed state guidelines for such postings. This deficiency had the potential to affect all 57 residents in the facility.
Failure to Provide Required Notices and Advocacy Contact Information
Penalty
Summary
The facility failed to provide required written notices and contact information for advocacy groups and instructions on how to file a complaint with the State Agency to four residents who were reviewed for these requirements. All four residents had intact cognition and required varying levels of assistance with activities of daily living due to diagnoses such as heart failure, depression, chronic pain, anxiety, spina bifida, and muscle weakness. Despite the facility's policy stating that residents would be given a list of names, addresses, and telephone numbers for pertinent regulatory agencies and advocacy groups, these residents were not aware of the Long-Term Care Ombudsman or how to contact the State Agency. During interviews, two residents stated they did not know what a Long-Term Care Ombudsman was or how to contact one, and all four residents indicated they did not know how or why to contact the State Agency. Staff interviews revealed that residents were only reminded of a poster with the required information at the main entrance, and staff were not actively informing residents about the Ombudsman or reporting procedures. The administrator acknowledged that the facility had not fully met regulatory requirements regarding resident notices and contact information.
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