Failure to Post and Review Resident Rights
Summary
The facility failed to ensure that resident rights were posted on the 100 Hall, a locked, secured unit, and did not review resident rights with residents at least annually. During a resident council meeting, seven out of eight residents reported that staff did not verbally go over or review resident rights with them. Observations on multiple occasions confirmed that resident rights were not posted in the 100 Hall. The facility's policy required that resident rights be communicated both orally and in writing in a language understood by the resident and reviewed annually with each resident or their representative. Interviews with the Social Services Director and the Director of Nursing revealed that the previous Activity Director, who was responsible for conducting resident council meetings, did not review resident rights with residents. The Director of Nursing expected resident rights to be discussed during these meetings and reviewed annually, with documentation signed and scanned into the resident's chart. However, it was confirmed that currently, no staff member was verbally reviewing resident rights with residents. The Administrator also expected resident rights to be posted on the 100 Hall and discussed during resident council meetings.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
