Failure to Establish Resident Visitation Rights Compliance
Summary
The facility failed to establish a structure to comply with resident visitation rights and ensure equal visitation privileges. During the survey, it was discovered that no personnel were assigned to monitor compliance with resident rights. The resident rights policy and procedure, reviewed with the institutional program director, was found to be hospital-based and included the logo of Episcopal Hospital San [NAME] Metro, indicating it was not tailored to the facility's specific needs. Additionally, the policy was a 13-page document that included all 483.10 resident rights statements in one policy, lacking individualized mechanisms to ensure compliance with CMS Medicare requirements.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with dementia and depression was not informed by facility staff of a visitation restriction placed on her family member due to safety concerns involving staff. The facility did not document or communicate the restriction to the resident, instead relying on another family member to relay the information, and did not follow its own policy requiring notification of visitation rights and restrictions.
A resident who is bedbound and cognitively intact was denied visitation from her best friend after a roommate objected to the visitor's presence. Staff escorted the visitor out, and no alternative arrangements were made to support the resident's right to receive visitors, despite facility policy and staff acknowledgment of this right.
A resident with moderate cognitive impairment and multiple diagnoses was not allowed to have private visits with their daughter due to restrictions imposed by their grandson, who did not have power of attorney. Staff followed the grandson's instructions to limit visits, despite the resident's wishes and facility policy guaranteeing 24-hour access to visitors of the resident's choice. The administrator was unaware of these restrictions.
A resident was not allowed to have visitors in her room and was only permitted to meet with friends in the common area, as directed by staff. Staff interviews revealed inconsistent understanding of visitation rules, and the facility only had a hospital-wide policy, not one specific to LTC. Staff confirmed there was no developed or communicated visitation policy for long-term care services, affecting all residents and their visitors.
The facility did not follow its own policy allowing 24-hour visitation, instead requiring all visitors to leave by 8:00PM each day. This practice was confirmed by a family member, multiple residents, and staff, and had the potential to affect all residents in the facility.
A resident's visitation rights were violated when her husband was restricted to visiting only during business hours, causing her depression and financial hardship. Despite the facility's policy allowing unrestricted family visits, the restriction was based on an unsigned document with unsubstantiated claims. Interviews revealed no significant issues with the husband, yet the facility cited safety concerns without formal grievances or police reports.
Failure to Inform Resident of Visitation Rights and Restrictions
Penalty
Summary
The facility failed to inform a resident of her visitation rights and the related facility policy and procedures, including any safety restrictions or limitations, the reasons for such restrictions, and to whom the restrictions applied. This deficiency was identified for one resident who was not notified by the facility when her family member was no longer allowed to visit due to safety concerns. The resident, who had diagnoses of dementia, adjustment disorder, and depression, reported feeling lonely and isolated, and stated she missed her family member, who had not been allowed to visit for several months. She also stated she never received any policy or notice about the visitation restriction. Interviews with facility staff, including the former DON, social worker, administrator, and ADON, revealed that the family member was restricted from visiting after incidents involving inappropriate behavior toward a staff member, which led to police involvement. The administrator and other staff members confirmed that the decision to restrict visitation was made for staff safety, but there was no documentation in the resident's medical record regarding the restriction, nor evidence that the resident was formally informed by facility staff. Instead, it was believed that another family member had informed the resident about the restriction. The facility's own policy required informing residents and/or their representatives of their visitation rights and any clinical or safety restrictions. However, the administrator acknowledged that the resident rights policy was not reviewed or followed when addressing the visitation issue, and the incident was handled primarily from the perspective of staff safety. There was no documentation or formal communication to the resident regarding the restriction, resulting in the resident being unaware of her rights and the reasons for the limitation.
Failure to Ensure Resident Visitation Rights in Shared Room
Penalty
Summary
The facility failed to ensure that a resident's right to full and equal visitation privileges was honored. A cognitively intact resident, who is bedbound and requires assistance with personal care, was denied visitation from her best friend after a roommate objected to the visitor's presence. The roommate, who has resided in the facility for many years, became upset and demanded that the visitor leave, believing the visitor to be a funeral director. Staff, including CNAs, LPNs, and the Social Services Director, responded by escorting the visitor out of the room, despite the resident's wishes to continue the visit. The resident expressed anger and frustration that her right to receive visitors was violated, especially since her friend assists her with essential tasks such as managing her link card, grocery shopping, and laundry. Multiple staff members acknowledged that the resident had an equal right to receive visitors in her room, as supported by facility policy. However, no alternative arrangements were made to facilitate the visit after the roommate's objection, and the visitor was not allowed to return. The Assistant Administrator did not follow up with the visitor or the resident to resolve the situation, and the resident's ability to receive her chosen visitor was not restored. Facility documentation and interviews confirm that the resident's visitation rights were not upheld in accordance with her preferences.
Failure to Ensure Resident Visitation Rights
Penalty
Summary
The facility failed to ensure that a resident was allowed to have visitors of their choice, as required by visitation rights. The resident, who had diagnoses including depression and hypertension and was assessed as moderately cognitively impaired, reported that their grandson was preventing their daughter from visiting them in their room. The resident expressed a desire for private visits with their daughter and stated that they had informed the social services director about the issue, but no action was taken. The grandson, who did not have power of attorney, instructed staff to only allow visits in the lobby or outside and requested that a witness be present during visits due to ongoing arguments between the daughter and grandson. Staff, including the housekeeping supervisor and an LPN, confirmed that the grandson did not have legal authority over the resident and that the resident was their own responsible party. Despite this, staff followed the grandson's instructions regarding visitation restrictions. The administrator was unaware that the resident's visitation rights were being restricted by the grandson. The facility's policy stated that residents should have 24-hour access to visitors of their choice with the resident's consent, but this policy was not followed in this case.
Failure to Develop and Communicate LTC-Specific Visitation Policy
Penalty
Summary
The facility failed to develop, implement, and inform residents of a specific visitation policy and procedure for long-term care services. One resident reported being restricted from having visitors in her room and was only allowed to meet with friends in the common area, as directed by staff. The resident stated she complied with this arrangement to avoid conflict with staff. Multiple staff interviews revealed inconsistent understanding and application of visitation policies, with some staff indicating that overnight visits required prior approval and others referencing a general hospital policy rather than one tailored to long-term care. Upon request, the facility provided a visitation policy that was specific to the hospital system and not applicable to the long-term care setting. Staff confirmed that there was no developed policy or procedure for visitation related to Senior Services or long-term care. This lack of a specific and communicated visitation policy had the potential to affect all residents and their visitors, as it resulted in inconsistent practices and lack of clarity regarding residents' visitation rights.
Failure to Allow 24-Hour Visitation as Required by Facility Policy
Penalty
Summary
The facility failed to follow its own visitation policy, which allows for 24-hour access for immediate family, other relatives, and authorized persons with the resident's consent. Instead, the facility enforced a policy requiring all visitors to leave by 8:00PM each day. This was confirmed through interviews with a family member/POA, several residents during a resident council meeting, the nursing supervisor, and the receptionist. The family member/POA reported being asked to leave by 8:00PM, with the nursing supervisor monitoring their departure. Residents also confirmed that visitors are routinely made to leave at 8:00PM. Staff interviews further corroborated that the facility's practice was to end visitation at 8:00PM, with the receptionist and nursing supervisor coordinating to ensure all visitors exited the building at that time. This practice was in direct contradiction to the facility's written policy, which permits 24-hour visitation for certain individuals. The daily census indicated that this failure had the potential to affect all 154 residents residing in the facility.
Visitation Rights Violation Leads to Resident Harm
Penalty
Summary
The facility failed to ensure that a resident, identified as R5, had the right to receive visitors of her choosing at the time of her choosing, as required by the facility's visitation policy. R5's husband was restricted to visiting only between the hours of 8:00 AM and 4:30 PM, despite the resident's wishes and without a valid reason provided to R5 or her husband. This restriction was imposed based on an unsigned document that claimed R5's health and wellness were compromised by her husband's presence, although no evidence was provided to support this claim. R5, who is cognitively intact with a BIMS score of 15, has multiple medical diagnoses, including multiple sclerosis and chronic pain, and her care plan includes visits from her husband as a preferred activity. The restriction on her husband's visitation hours has led to R5 experiencing depression, financial hardship, and disinterest in participating in activities of daily living. The facility's actions have also limited R5's ability to visit with her child, who is only in the area for the summer, further contributing to her psychosocial harm. Interviews with facility staff and other residents revealed no significant issues or threats posed by R5's husband, except for one incident where he was reported to have used vulgar language towards a staff member. Despite this, the facility continued to enforce the visitation restriction, citing concerns about staff safety and the husband's intimidating behavior. However, no formal grievances or self-reports were filed, and the police were only called to ask the husband to leave the premises after hours, with no charges filed against him.
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.
