Failure to Ensure Cognitive Ability Before Signing Arbitration Agreements
Summary
The facility failed to ensure that residents had the cognitive ability to understand and sign binding arbitration agreements. This deficiency was identified for four residents who were assessed to have severely impaired cognition, as indicated by their Brief Interview for Mental Status (BIMS) scores. Resident 71 had a BIMS score of six, while Residents 84, 75, and 44 each had a BIMS score of one, all indicating severe cognitive impairment. Despite this, these residents signed arbitration agreements without the necessary cognitive capacity to understand the terms. In the case of Resident 71, the resident's niece was present during the signing but did not have power of attorney. The niece understood the agreement but chose not to sign it herself, allowing the resident to sign instead. For Resident 84, the Admissions Coordinator communicated with the resident's grandson over the phone, who explained the agreement in Spanish to the resident. However, the Admissions Coordinator could not verify the resident's understanding due to the language barrier. Resident 75's daughter, who did not have power of attorney, explained the agreement to her mother in Spanish and permitted her to sign it. Resident 44, who had no legal representative or family, signed the agreement after a friend, contacted by phone, gave verbal consent. Interviews with the Admissions Director and Admissions Coordinator confirmed that these residents lacked the cognitive ability to comprehend the agreements they signed. The facility's Administrator acknowledged that it was unacceptable for residents to sign arbitration agreements without understanding them and stated that such instances should be considered refusals if the resident or their representative did not wish to sign.
Plan Of Correction
1/7/25 The [R] Agreements for R71, R84, R75 and R44 were rescinded. A facility wide audit was completed on all signed [R] Agreements in comparison to Brief Interview for Mental Status (BIMS) Assessment score and were corrected. All residents have the potential to be affected by this deficient practice. The Administrator inserviced the Admissions Department on the proper procedure for conducting Arbitration Agreements in accordance to their Brief Interview for Mental Status (BIMS) Assessment score. The Minimum Data Set (MDS) Coordinator will audit 3 new admissions per month for accurate Arbitration Agreements signature in accordance to Brief Interview for Mental Status (BIMS) Assessment score. The Minimum Data Set (MDS) Coordinator will report the results of these audits to the Administrator on a monthly basis. The Minimum Data Set (MDS) Coordinator will review the findings of the monthly audits at the Quarterly QAPI Meeting for the next 2 quarters.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A facility failed to clearly separate the arbitration agreement from the admission agreement and did not ensure residents or representatives could sign admission paperwork without also agreeing to binding arbitration. The admission packet tied the dispute resolution provision to the admission agreement, while residents with intact cognition said they did not know what an arbitration agreement was, did not remember signing one, or were unsure if they had signed one; resident council attendees also said they were unaware of any arbitration agreement.
A resident admitted with major depressive disorder had a binding arbitration agreement signed by the family representative after all admission paperwork was presented together. The family representative said the agreement was not explained and they did not know it was optional. Staff interviews and facility policy confirmed the agreement should be clearly explained, including that it is optional and that signing waives the right to a trial.
A resident with a hx of TIA, HF, and weakness had a binding arbitration agreement in the record signed by the resident instead of the designated HCPM daughter. The daughter stated the agreement was not discussed with her, while the AC said arbitration is explained if not understood and that the resident or representative should verbally acknowledge understanding before signing.
Arbitration Agreement Not Fully Explained to Resident with Cognitive Impairment A resident with moderately impaired cognition and Vietnamese as a primary language signed a 5-page arbitration agreement after it was reviewed with translation help from a Vietnamese-speaking nurse. Later, the resident said they did not remember signing the document and did not know what it was, and the record did not show a witness signature or detail how the complex admission packet was explained in a way the resident could understand.
Failure to Explain Arbitration Agreement Terms: A resident with encephalopathy and severely impaired cognition had an AA signed by the RP, but the RP said he was not given a copy and was not told the agreement was optional or that it could be rescinded within 30 days. The BOA stated he explained that an arbitrator would decide disputes instead of a jury, but he did not know about the 30-day rescission option, while the BOM stated staff were expected to explain the AA’s purpose and that signing was not required for admission.
Two residents were involved in arbitration agreements that were signed without clear evidence they understood the documents. One resident with intact cognition said they did not recall authorizing anyone to sign for them, while another resident said they did not receive an explanation and just signed where they were told to sign. The SSD stated they had no training on arbitration agreements and handled them as part of the admission packet.
Arbitration Agreement Not Clearly Separated From Admission Packet
Penalty
Summary
The facility failed to clearly distinguish the arbitration agreement from the admission agreement and did not ensure residents or their representatives could sign the admission agreement without also consenting to the facility’s arbitration agreement. The admission packet’s introductory note stated that the admission agreement, including the dispute resolution provision/agreement, represented an agreement between the resident, the resident representative if applicable, and the facility. The dispute resolution section stated that by entering into the agreement both parties waived the right to have disputes decided in court and instead accepted binding arbitration as the sole means of dispute resolution, while also stating that arbitration was not a condition of admission or continued care. The administrator identified 68 residents in the facility, and the administrator and admissions coordinator stated all 68 residents or representatives had agreed to arbitration. Residents with intact cognition, including several with BIMS scores of 14 or 15, told the surveyor they did not know what an arbitration agreement was, did not remember signing one, or were unaware whether they had signed one. During resident council, attendees stated no one knew what an arbitration agreement was. The admissions coordinator stated that if a resident did not want to sign the arbitration agreement, signatures would be stopped and the packet would be reprinted so the resident would not have to sign it, and said a script was read explaining the resident did not have to sign and had 30 days to rescind in writing. The administrator stated a script was read during admission discussions and that if the resident said they understood, the administrator believed them.
Binding Arbitration Agreement Not Clearly Explained
Penalty
Summary
The facility failed to ensure that a binding arbitration agreement was explained in a manner understandable to the family representative of Resident 25. Resident 25 was admitted to the facility in March 2026 with a diagnosis of major depressive disorder. During an interview, the family representative stated they completed the admission paperwork and signed the binding arbitration agreement after being given all of the admission paperwork at one time and told to sign it. The family representative stated the agreement was not explained and that they did not understand it was optional. Facility staff interviews confirmed that the binding arbitration agreement was provided with the admission paperwork. The Resident Relations Liaison stated it was important to tell residents that the agreement was optional and not a condition of admission, but also stated that when the agreement was given to the family representative, it was not explained line by line. The Clinical Liaison stated residents and representatives needed to understand they were waiving the right to a trial when signing the agreement and that it was important to explain that it was optional and not required for admission. The facility policy stated residents or representatives are to be informed of the nature and implications of proposed binding arbitration agreements, that the optional nature of the agreement is to be clearly communicated, and that the terms are to be explained in a way that ensures understanding.
Arbitration Agreement Not Explained to Designated Representative
Penalty
Summary
The facility did not ensure that Resident 79’s binding arbitration agreement was explained to and signed by the resident’s designated representative. Resident 79’s admission record showed diagnoses including a history of TIA, heart failure, and weakness, and identified the resident’s daughter as the healthcare decision maker. However, the arbitration agreement in the record showed a signature indicating Resident 79 signed the document rather than the daughter. During interview, the daughter stated that the arbitration agreement was not discussed with her. The admission coordinator stated that if a resident or representative does not understand arbitration, an explanation is provided, and that some individuals sign and others decline. The facility policy stated that residents or representatives are to be informed of the nature and implications of binding arbitration agreements, that the terms are to be explained in a way that ensures understanding, and that the resident or representative must verbally acknowledge understanding before signing.
Arbitration Agreement Not Fully Explained to Resident with Cognitive Impairment
Penalty
Summary
The facility failed to ensure Resident 133 entered into a legally binding arbitration agreement only after fully understanding its terms, and the required explanation of the agreement was not provided in a form and manner the resident could understand. During an observation and interview in the resident’s room, Resident 133 and the resident’s friend were shown a paper copy of the arbitration agreement that had been signed earlier, and Resident 133 stated they did not remember signing it and did not know what the document was. The friend stated that Resident 133 does not have a good memory. Record review showed the arbitration agreement for Resident 133 was signed by the resident and later by the Admissions Assistant. The Admissions Assistant stated that Resident 133’s primary language is Vietnamese and that a Vietnamese-speaking nurse helped translate and review the five-page arbitration agreement with the resident, but there was no witness signature documented. The Marketing-Admissions Note stated that the admissions packet was reviewed at the bedside with translation assistance and that Resident 133 verbalized understanding, but it did not describe how the extensive and complex packet, including the arbitration agreement, was reviewed with a resident who had a BIMS score of 10, indicating moderately impaired cognition.
Failure to Explain Arbitration Agreement Terms
Penalty
Summary
The facility failed to ensure that the arbitration agreement was adequately explained so the resident’s responsible party could understand its terms for one sampled resident. Resident 65 was admitted with diagnoses including encephalopathy, and the history and physical dated 4/4/2026 stated that the resident did not have the capacity to understand and make decisions. The MDS dated 4/7/2026 indicated severely impaired cognition and dependence or substantial/maximal assistance with multiple activities of daily living, including toileting hygiene, bathing, dressing, oral hygiene, and eating. Resident 65’s arbitration agreement, dated 4/9/2026, was signed by Family Member 1. During interview, Family Member 1 stated he signed the agreement but did not receive a copy, and he was not told that the agreement was not required for admission or that it could be rescinded within 30 days if not understood. The Business Office Assistant stated he explained that the arbitration agreement involved a neutral third party deciding the outcome instead of a jury, but he did not know and did not inform residents or responsible parties that it could be rescinded within 30 days. The Business Office Manager stated the Business Office Assistant was expected to explain the purpose of the agreement, that signing was optional and not required for admission, and that the agreement could be canceled within 30 days. The facility policy titled Binding Arbitration Agreement stated that the resident or representative must be explicitly informed of the right not to sign the agreement as a condition of admission or as a requirement to receive care.
Residents Signed Arbitration Agreements Without Clear Understanding
Penalty
Summary
The facility failed to ensure residents understood binding arbitration agreements before signing them for 2 of 2 sampled residents reviewed. For one resident, an arbitration agreement dated 09/29/25 showed the resident representative’s name printed on the signature page, while the SSD signed in the facility representative area. The resident’s admission assessment dated 10/05/25 showed a BIMS score of 15, indicating intact cognition and ability to make decisions of daily living. When interviewed on 04/22/26, the resident stated they did not recall giving anyone permission to sign an arbitration agreement for them and said they were not in their right mind when admitted because of their condition. For the second resident, an arbitration agreement dated 04/08/26 also showed the resident’s name printed in the resident representative section, with no resident signature on the signature page and the SSD signing in the facility representative area. The resident’s admission assessment dated 04/15/26 showed a BIMS score of 14, indicating intact cognition and ability to make decisions of daily living. During interview, the resident stated they did not recall signing an arbitration agreement, did not receive an explanation of what they signed at admission, and said they just signed where they were told to sign. The SSD stated they had not received training on arbitration agreements and oversaw them as part of the admission packet; they also stated they did not recall any resident reading the entire document. The SSD further stated they read the admission documents to the first resident and signed for them because the resident was too shaky at the time.
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