Failure to Establish Resident Rights Compliance Structure
Summary
The facility failed to establish a structure to comply with the resident's right to choose or refuse to perform services for the facility. 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 the Episcopal Hospital San [NAME] Metro, indicating it was not tailored to the facility's specific needs. Additionally, the policy did not include individualized mechanisms to ensure compliance with CMS Medicare requirements. The policy was a 13-page document that included all 483.10 resident rights statements in one policy, lacking specificity and clarity for implementation in the facility.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with ASD, ADHD, and intermittent explosive disorder was cognitively intact and his own decision maker, yet the facility did not allow him to continue a voluntary lawn-mowing/yard-work arrangement he had previously done and wanted to keep doing. Records showed he had enjoyed mowing with staff, his care plan included yard activities, and a signed volunteer work safety agreement was completed, but MOD later stopped the plan because of safety and liability concerns. Staff acknowledged the resident had been expected to work and that the facility did not provide the work services that had been chosen.
A resident in a therapeutic stipend program at an LTC facility experienced a delay in receiving payment for services rendered in November. The resident, who was cognitively intact and required assistance with daily activities, participated by calling Bingo and working in the soda store. The delay was due to the activity director's error in submitting the payment request, resulting in the stipend being paid in December.
Resident Not Allowed to Continue Voluntary Work Arrangement
Penalty
Summary
The facility failed to ensure that a resident who had expressed a desire to work and had previously worked with facility staff was given the choice to perform voluntary services at the facility. Resident 44 was admitted with diagnoses including Autistic Disorder, ADHD, and Intermittent Explosive Disorder. The resident’s 03/04/2026 comprehensive assessment showed the resident was cognitively intact and able to make needs known, and the record also showed the resident became an adult and their own responsible decision maker in January 2026. The record and interviews showed Resident 44 had a history of mowing lawns and doing yard work with staff in 2025 and had continued interest in those activities. During observation and interview, the resident stated they liked mowing lawns, had done so the prior year, wanted to keep working, and did not understand why they were no longer allowed to continue. The care plan identified preferred activities including video games, watching TV, building/fixing things, yard work, and lawnmowers, and stated the resident was to actively participate in gardening and yard activities. Recreation records showed the resident participated in lawn mowing with staff in September 2025 and enjoyed the activity. Staff interviews showed that a volunteer work safety agreement was developed and signed on 03/27/2026 by Resident 44, Staff V, and Staff W for outdoor lawn care, landscaping, and related tasks. Staff V stated the resident had completed the requirements and that the plan was to work with MOD staff, but MOD later stopped the arrangement because of safety and liability concerns. Staff W and Staff Y stated they were concerned about the use of a gas-powered lawnmower and who would be liable if the resident were injured. Staff B stated the resident had the right to perform voluntary work and that it had already been implemented in the care plan, while Staff A stated the facility did not provide the resident the work services that had been chosen and planned, and said, "We failed (Resident 44) in that situation."
Resident Payment Delay in Therapeutic Stipend Program
Penalty
Summary
The facility failed to ensure that a resident participating in the Resident Therapeutic Stipend Program was compensated in a timely manner for services rendered. The resident, who was cognitively intact and required assistance with daily activities, participated in the program by calling Bingo and working in the resident soda store. Despite completing her work program commitment log for November 2024, the resident did not receive her stipend until December 12, 2024, which was during the survey. The delay in payment was attributed to the activity director, who was new to the role and did not submit the payment request correctly for November 2024. This error caused a delay in the issuance of the stipend check, which was eventually cashed and deposited into the resident's petty cash account. The business office manager confirmed that there was inconsistency in receiving checks from corporate, which contributed to the delay in payment.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.