Failure to Review Resident Rights in Council Meetings
Summary
The facility failed to ensure that resident rights were reviewed on an ongoing basis. A review of the resident council's monthly meeting minutes from May 2024 through October 2024 showed that resident rights were not reviewed during these meetings, nor was resident rights information disseminated to the resident council or residents in general. An interview with the resident council confirmed that the facility did not review resident rights during their meetings and did not routinely provide resident rights information. The Therapeutic Recreation Director stated that residents received a Resident's [NAME] of Rights upon admission, but there was no designated time to review these rights during meetings, and the facility lacked policies addressing the resident council. The Administrator indicated that the recreation department was responsible for conducting the resident council meetings and expected the recreation staff to review resident rights with the residents during these meetings.
Penalty
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Surveyors found that multiple self-responsible residents did not receive or sign admission agreements at or near the time of admission, contrary to facility policy. One resident’s agreement was signed eight days after admission, another resident had no signed agreement on file, a third resident’s agreement was only provided on the day of discharge and the family reported being unaware of the care and services provided, and a fourth resident signed the agreement more than a month after admission. The admission agreement, which includes resident rights, advance directives, facility and Ombudsman information, arbitration terms, and expectations, was required by policy to be signed at admission and filed in the clinical record.
The facility failed to provide ongoing, understandable education on Resident Rights to its residents and/or their representatives. During a Resident Council meeting, residents reported they were unaware of having rights, did not know what those rights were, and did not know if they were posted in the facility. Review of several months of Resident Council minutes showed that leadership attended but did not provide Resident Rights education. The Life Enrichment Director acknowledged that staff had not been reviewing or educating residents on their rights during these meetings, and the DON stated that Resident Rights were only given at admission and not reviewed on an ongoing basis. Neither could confirm that Resident Rights were posted and readily available, despite facility policy requiring that residents be informed of their rights and that these rights be posted throughout the facility.
A resident with multiple serious medical conditions and moderate cognitive impairment was admitted without receiving or acknowledging the required notice of rights, as documented in facility policy. The admission paperwork was incomplete, and the electronic health record did not contain evidence that the resident or their representative had been informed of their rights at admission.
The facility did not review resident rights during Resident Council meetings, as confirmed by both the Activity Director and Resident Council members. The Administrator acknowledged that resident rights were expected to be reviewed at these meetings, but this was not done.
A resident with a history of substance abuse and traumatic brain injury was admitted and subsequently readmitted without receiving the required admission packet or notice of resident rights. Staff interviews confirmed that neither the resident nor the family member received this information due to behavioral incidents and lack of communication among staff responsible for admissions. Facility policy requires provision and acknowledgment of these documents, but this process was not followed, and the necessary documentation was missing from the resident's record.
A resident with dementia, hypertension, and atrial fibrillation experienced a fall after a private 1:1 aide, who was only supposed to sit with the resident, attempted a transfer without proper authorization. The facility only provided verbal, not written, information to residents and their representatives about the rule prohibiting private aides from providing direct care.
Failure to Provide Timely Admission Agreements and Notice of Rights
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide residents with notice of rights, rules, services, and charges prior to or upon admission, as required by facility policy. The Admissions Director stated that the admission agreement is very important because it includes information on resident rights, advance directives, facility and Ombudsman information, arbitration, and expectations, and that it should be signed within 72 hours of admission. However, record review showed that one resident, who was self-responsible and had an emergency contact listed, was admitted on a specified date and transferred to the hospital after a medical emergency, yet the state-specific admission agreement was not signed by the resident representative until eight days after admission. Another self-responsible resident with an emergency contact listed had no signed admission agreement in the clinical record, as confirmed by the ADON during concurrent interview and record review. For a third self-responsible resident, records showed admission on a specified date and discharge home on another date, with the emergency contact listed; the resident’s representative reported that the admission agreement was only given on the day of discharge, and that the resident and family were unaware of the care and services provided while at the facility. The state-specific admission agreement for this resident was dated the day the resident went home. For a fourth self-responsible resident, the admission agreement was signed more than one month after admission. Review of the facility’s policy and procedure titled “Admission Agreement,” last revised December 2025, indicated that each resident must have an admission agreement signed and dated by the resident or resident representative at the time of admission and filed in the clinical record, which did not occur for these four of five sampled residents.
Failure to Provide Ongoing, Understandable Education on Resident Rights
Penalty
Summary
The facility failed to provide ongoing education to residents and/or their representatives on Resident Rights in a format that was understandable to them. During a Resident Council meeting, residents present reported they were unaware that they had rights, did not know what their Resident Rights were, and did not know if these rights were posted within the facility. Review of Resident Council minutes for three consecutive months showed that various facility leaders attended the meetings but did not provide education on Resident Rights. During the same Resident Council meeting, the Life Enrichment Director stated she typically led the council and that an Activity Coordinator filled in when she was unavailable, and she acknowledged that staff had not been reviewing or educating residents on Resident Rights during these meetings. The DON stated that Resident Rights were provided only as part of admission packets and agreed they needed to be reviewed with residents on an ongoing basis, and neither the Life Enrichment Director nor the DON could confirm that Resident Rights were posted and readily available for residents, despite the facility’s Resident Rights policy stating that residents were to be informed of their rights and that these rights were to be posted throughout the facility. No specific resident medical histories or clinical conditions were described in relation to this deficiency, and the census at the time was 28 residents.
Failure to Provide Notice of Resident Rights on Admission
Penalty
Summary
The facility failed to provide a notice of resident rights upon admission for one resident. According to the facility's own admission policy, residents or their representatives must be informed of their rights and facility policies both orally and in writing, with accommodations for impairments and language needs. The policy also requires written acknowledgment of this explanation to be documented in the admission agreement. Record review showed that for the resident in question, who was admitted with diagnoses including osteomyelitis, intracranial injury with loss of consciousness, quadriplegia, and depression, there was no documentation in the electronic health record indicating that the resident or their representative received or acknowledged the notice of rights at admission. Further review revealed that the resident had a moderate cognitive impairment, as indicated by a BIMS score of 11, and had a designated health care power of attorney. Interviews with the Admissions Director confirmed that the admission paperwork, including the required notice of rights, had not been completed at the time of admission, and the medical record lacked the necessary documentation to show that the resident or their representative had received this information.
Failure to Review Resident Rights During Resident Council Meetings
Penalty
Summary
The facility failed to ensure that residents were informed of their rights both orally and in writing on an ongoing basis. A review of Resident Council meeting minutes from three separate dates showed that resident rights were not reviewed during any of the meetings. During interviews, the Activity Director confirmed that resident rights were not discussed at Resident Council meetings, and members of the Resident Council also stated that these rights were not reviewed. The Administrator acknowledged that the expectation was for resident rights to be reviewed with residents during these meetings, but this did not occur.
Failure to Provide Resident Rights and Admission Packet Upon Admission
Penalty
Summary
The facility failed to provide a notice of rights and services to a resident prior to or upon admission, as well as during the resident's stay, and did not ensure receipt and written acknowledgment of such information. The resident in question was admitted with a history of psychoactive substance abuse, traumatic brain injury, and a recent traumatic subarachnoid hemorrhage. Upon admission and subsequent readmission, neither the resident nor the family member received the required admission packet or information regarding resident rights, as confirmed by interviews with the family member, administrator, and other facility staff. The deficiency was further substantiated by staff interviews, which revealed that the admission packet, containing essential information such as resident rights, consent forms, and facility policies, was not provided due to the chaotic circumstances surrounding the resident's behavioral issues. The administrator acknowledged that the admission packet was not given because of the behavioral incidents that occurred shortly after admission. The receptionist, who was responsible for distributing admission packets on weekends, stated she did not receive instructions to provide the packet to the resident or family member during the relevant period. Facility policies reviewed indicated that it is standard procedure to provide residents and their representatives with written information about their rights and services, and to obtain a signed acknowledgment for the clinical record. However, in this case, the process was not followed, and the required documentation was not present in the resident's record. The family member also reported not receiving any incident report or information about the resident's rights, and was not informed about the process for appealing a discharge.
Failure to Provide Written Notice of Facility Rules Regarding Private Companions
Penalty
Summary
The facility failed to provide residents or their representatives with written information regarding facility rules about private companions not being permitted to provide direct care to residents. Although the facility's policy states that a written description of resident rights will be provided upon admission and upon request, interviews confirmed that only verbal information was given about the restriction on private aides providing direct care. This omission was identified during a review of facility documentation and staff interviews. This deficiency was identified in the context of a resident with dementia, hypertension, and atrial fibrillation who experienced a fall in their room. The incident report revealed that a private 1:1 aide, who was present to sit with the resident, attempted to transfer the resident from bed to wheelchair and subsequently lowered the resident to the floor. The nurse later informed the aide that the resident required a two-person transfer due to their condition. The lack of written communication regarding the facility's rules for private aides contributed to the incident.
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