Failure to Honor Resident's Clothing Choice
Summary
The facility failed to honor a resident's right to choose personal clothing, as evidenced by the case of a resident who was consistently dressed in a hospital gown against his expressed wishes. The resident, who had intact cognitive skills as indicated by a Brief Interview for Mental Status (BIMS) score of 14, expressed a desire to wear normal clothes instead of the hospital gown he was observed wearing during multiple interviews. Despite his clear preference, staff interviews revealed a misunderstanding of the resident's wishes, with some staff believing it was his preference to wear the gown, while others cited behavioral issues as the reason for the gown. The facility's documentation was incomplete and inconsistent, failing to record any behaviors or interventions related to the resident's clothing preferences. The Medication Administration Record (MAR) and Treatment Administration Record (TAR) lacked documentation of any refusal to get dressed, and there were missing entries for several days. The Care Plan and other records did not document any behaviors or interventions related to the resident's clothing choice, despite staff claims of behavioral issues. The Director of Nursing acknowledged the documentation gaps and stated that her expectation was for complete and accurate documentation, including tracking of any behaviors and interventions. Interviews with staff members revealed a lack of communication and understanding regarding the resident's clothing preferences. Some staff believed the hospital gown was used as a behavioral intervention, while others thought it was the resident's choice. The Director of Nursing expected staff to honor residents' clothing choices and document any refusals or interventions, but the facility's records did not reflect this practice. The facility's policy on resident rights emphasized the importance of allowing residents to retain and use personal possessions, but this was not upheld in the case of the resident in question.
Penalty
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Several residents expressed a desire to eat in the dining room, but the facility failed to provide a comfortable environment due to inadequate heating. Temperatures in the dining room and other common areas were consistently low, as the main boiler was non-functional and auxiliary heaters were insufficient. As a result, all meals were served in residents' rooms, and residents' choices regarding dining location were not supported.
Three residents with significant physical limitations and intact cognition did not consistently receive scheduled showers as required, with missing or incomplete documentation and reports from both residents and staff confirming missed care. Facility policy required documentation of showers or refusals, but this was not followed, resulting in a failure to support resident choice and self-determination.
A resident with ALS and dysphagia was kept on a pureed diet without supporting medical assessments, despite repeatedly expressing a desire to return to a regular diet. The facility did not offer alternative food options or document informed refusal, and staff confirmed that only pureed food was provided until further swallow studies were completed, failing to support the resident's right to self-determination.
A resident with multiple neurological diagnoses and a history of family conflict was transferred to another facility without documented evidence that she participated in or agreed to her discharge plan. Despite indications of intact cognition and requests for a court-appointed guardian, staff did not document any conversations with the resident about her involvement in the discharge process, resulting in a failure to support resident self-determination.
A resident with multiple medical conditions and intact cognition was not transported to a scheduled medical appointment after the facility became aware that transportation was unavailable. No documentation showed attempts to arrange alternative transportation, and the resident was not informed of the cancellation, leading to confusion and frustration. The facility's admission agreement included transportation as a provided service.
A resident with severe cognitive and physical impairments was not provided medications as ordered with yogurt or pudding, despite a clear physician order and the resident's stated preference. Staff administered medications with applesauce when yogurt was available in the kitchen but not on the unit, and did not check for its availability. Additionally, staff failed to assist the resident out of bed before lunch as ordered, documented the task as completed without performing it, and did not record any refusals. These actions were confirmed through staff interviews, record reviews, and direct observation.
Failure to Accommodate Resident Dining Preferences Due to Inadequate Heating
Penalty
Summary
The facility failed to accommodate residents' preferences to eat in the dining room due to inadequate heating in common areas, including the dining room itself. Observations revealed that the temperatures in these areas, measured by the Maintenance Director using a hand-held infrared thermometer, ranged from 51.2 to 56.5 degrees Fahrenheit. The boiler responsible for heating these spaces was found to be non-functional and had been permanently shut off, with exposed wires visible in the boiler room. Auxiliary heaters were present but insufficient to make the dining room comfortable for regular use. Staff interviews confirmed that the dining room had not been used for meals or activities for two years, except for a single event where additional heaters were used. Resident interviews indicated a clear desire to eat in the dining room if the temperature were comfortable. One resident, who was cognitively intact and independent with eating, specifically expressed enjoyment in dining in the communal space but cited the cold as a deterrent. Other residents echoed this sentiment. The Administrator acknowledged that the dining room and other common areas had not been prioritized for heating due to cost concerns and stated that the focus was on maintaining resident room temperatures. As a result, all meals were served in residents' rooms, and the facility did not support or facilitate resident choice regarding dining location.
Failure to Provide Scheduled Showers and Document Care for Dependent Residents
Penalty
Summary
The facility failed to ensure that residents who were dependent on staff for bathing received showers on their scheduled days according to their preferences. Medical record reviews, resident and staff interviews, and documentation audits revealed that three residents with intact cognition and significant physical limitations did not consistently receive scheduled showers. For example, one resident with multiple sclerosis, COPD, and atrial fibrillation, who required maximal assistance and mechanical lift transfers, had no shower documentation for two consecutive months and confirmed missed showers. Another resident with a right lower leg fracture and bipolar disorder, requiring moderate assistance, did not receive a scheduled shower, with no documentation or record of refusal, and also reported missed showers. A third resident, with a left femur fracture and polyneuropathy, dependent on a wheelchair and requiring substantial assistance, did not receive a scheduled shower, and documentation was incomplete. This resident stated that she had not received a shower for over a week and described waiting for staff assistance that never occurred. Staff interviews confirmed inconsistencies in documentation and communication regarding shower schedules, with some confusion between day and night shift responsibilities. The Director of Nursing verified the absence of required documentation for the affected residents on the specified dates. Facility policy required staff to document when showers were performed or refused, including the reason for refusal, but this was not consistently followed. The lack of documentation and missed showers for residents dependent on staff for bathing constituted a failure to honor resident choice and self-determination, as well as a failure to follow established care plans and facility procedures.
Failure to Honor Resident Choice in Diet Texture
Penalty
Summary
A resident with multiple complex medical diagnoses, including ALS, dysphagia, and recent dental procedures, was admitted to the facility and subsequently placed on a pureed texture diet. The hospital discharge summary recommended a soft diet for an unspecified number of days following a dental procedure, but did not indicate a need for a long-term downgrade in diet texture. Despite this, the facility maintained a pureed diet order for the resident without documentation of appropriate medical tests or assessments, such as a modified barium swallow study, to justify the continued restriction. The resident, who was cognitively intact, repeatedly expressed dissatisfaction with the pureed diet and requested to revert to a regular texture diet, but there was no evidence that the facility offered this option or documented informed refusal with acknowledgment of risks. Interviews with the resident confirmed that he refused facility meals due to the pureed diet and had to purchase his own food, as no alternatives were provided. Staff interviews, including those with the dietitian, SLP, and LPN, confirmed that the resident was only offered pureed food and that changes to the diet order were contingent on further swallow studies, which had not been completed. The facility failed to honor the resident's right to self-determination and choice regarding diet texture, as required, by not facilitating or documenting the resident's informed choice to assume risk and select a different diet texture.
Failure to Ensure Resident Choice in Discharge Planning
Penalty
Summary
The facility failed to ensure that a resident was provided with choice and self-determination regarding discharge planning. The resident, who had diagnoses including cerebral infarction, non-traumatic intracerebral hemorrhage, aphasia, dysphagia, and memory deficit, was admitted with three daughters named as healthcare POAs. Despite a Brief Interview of Mental Status (BIMS) score indicating intact cognition, a physician letter later stated the resident had cognitive impairment and required assistance with decision making, also mentioning possible financial abuse. Progress notes documented the resident's attempts to change POA paperwork, her request for facility representation during family visits, and her expressed desire for a court-appointed guardian. The resident also stated she did not want two of her daughters involved, citing family conflict. Facility staff reported they would follow POA paperwork and the resident's wishes, but interviews with the DON and Social Services confirmed there was no documented evidence that the resident participated in or agreed to her discharge plan. The timing of the physician letter and the family's request for transfer was noted as suspicious, especially as it followed the resident's request for a court-appointed guardian. Social Services acknowledged that no conversations with the resident regarding her involvement in the discharge process or her agreement to the plan were documented, resulting in a failure to honor the resident's right to self-determination in discharge planning.
Failure to Provide and Communicate Transportation for Medical Appointment
Penalty
Summary
The facility failed to ensure that a resident was provided transportation to a scheduled medical appointment, despite being aware that transportation was unavailable. The resident, who had diagnoses including type 2 diabetes, vascular dementia, anemia, hypertension, and nicotine dependence, was cognitively intact with a BIMS score of 13. Documentation showed that as of 07/18/25, the facility knew transportation was not available, but there was no evidence that alternative arrangements were attempted so the resident could attend the appointment. On the day of the appointment, the resident prepared and waited at the front of the building for transport, but the van did not arrive. After inquiring with staff, the resident was informed that the appointment was cancelled due to the van being broken, but he had not been notified beforehand. The resident expressed confusion and frustration about not being kept informed, despite having requested updates. The dermatology office confirmed the appointment was scheduled and cancelled on the same day. The facility's admission agreement indicated that transportation services were among the physician-ordered services available to residents.
Failure to Honor Resident Preferences and Physician Orders for Medication Administration and Positioning
Penalty
Summary
The facility failed to honor a resident's preferences as ordered by the physician, specifically regarding medication administration and positioning before meals. The resident, who had severe cognitive impairment and multiple physical limitations, had a physician's order for medications to be crushed and given only with pudding or yogurt, and to be assisted out of bed before lunch and returned to bed after lunch as tolerated. Despite these orders, staff administered medications with applesauce when yogurt was unavailable in the unit, even though yogurt was present in the kitchen. Staff confirmed the resident's preference for yogurt and acknowledged not checking the kitchen supply. Additionally, staff did not consistently assist the resident out of bed before lunch, as ordered, and documented completion of this task in the MAR/TAR without actually performing it or documenting any refusals by the resident. Multiple observations showed the resident remained in bed during lunch and was not assisted out of bed as required. Interviews with staff confirmed that the resident was not routinely assisted out of bed before lunch, and that refusals were not documented. The failure to follow physician orders and honor the resident's preferences was corroborated by staff interviews, medical record reviews, and direct observations, demonstrating a lack of adherence to both the resident's rights and prescribed care.
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