Failure to Establish Resident Rights Compliance Structure
Summary
The facility failed to establish a structure to comply with the resident's right to be informed of their rights and the rules governing their conduct and responsibilities during their stay. During the survey, it was found that no personnel were assigned to monitor compliance with resident rights. The resident rights policy and procedure, reviewed with the institutional program director, was hospital-based and included the logo of Episcopal Hospital San [NAME] Metro, indicating it was not tailored to the facility. 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
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The facility failed to ensure the current RBOR was provided to residents and posted for residents, visitors, and staff to review. The RBOR displayed at the entrances to the first, second, and third floor units was dated 4/14/09. The administrator stated they were not aware of changes to the RBOR, and the facility had not yet ordered new postings for the units.
Resident rights were not reviewed verbally or in writing during resident council meetings, and the posted rights notice was outdated. Several residents stated the rights had not been reviewed, and the admin confirmed the meetings did not include this review and the poster was not current.
Failure to provide a resident with oral and written notice of rights, rules, services, and charges at admission. A resident with major depression, HF, pulmonary HTN, and dementia had no signed acknowledgment of resident rights in the record. The RP said she was not informed of the resident’s rights or service details and later discovered the resident had been taken off Lexapro without notification. The ADM confirmed there was no evidence the admission packet or resident rights information had been provided.
A facility failed to periodically inform 7 sampled residents of their rights after admission. During a resident council meeting, the residents stated staff did not review resident rights and that rights were not reviewed at council meetings, and meeting minutes from several months showed no documentation that rights were reviewed. The Administrator stated they did not know whether resident rights were routinely reviewed with residents.
Failure to Review Resident Rights in Council Meetings: Four cognitively intact residents who regularly attended resident council meetings did not recall resident rights ever being discussed, and meeting minutes did not document any review of rights. A resident rights poster was posted in a hallway, but the residents said they did not know where it was located. The LED could not find documentation that rights were reviewed, and the Admin said the process was not yet standardized.
A resident admitted after a hospital stay did not have a signed admission Agreement in the EMR, resulting in no documented written notice of rights, services, or charges. The Director of Guest Services described a standard process of assessing cognition, reviewing the Agreement with the resident or representative, and obtaining a signature within about 72 hours, but could not locate a completed Agreement for this resident and noted she had been the only Guest Services staff and was on vacation around the time of admission. A blank Agreement reviewed by surveyors showed that non‑covered service prices auto‑populate when the form is completed. The BOM and SSD confirmed that written information on room rates and non‑covered costs is contained in the admission Agreement and acknowledged that, for this resident, they only discussed costs verbally with the resident and her daughter, without any written documentation.
Outdated Resident Rights Notices Posted
Penalty
Summary
The facility failed to ensure the most up to date Nursing Home Resident Rights (RBOR) was provided to each resident and displayed for residents, visitors, and staff to review. On observation, the RBOR posted next to the double doors entering the first floor unit, second floor unit, and third floor unit was dated 4/14/09. During interview, the administrator stated at 8:26 a.m. that they were not aware there were changes to the RBOR, and later stated at 9:21 a.m. that they had started the process of providing updates to residents and resident representatives, but new postings for the units had not yet been ordered. The facility Resident Rights policy dated 10/24 indicated copies of resident rights were posted throughout the facility, but it did not address when the facility would provide notification of changes in State or Federal laws related to resident rights or facility rules during the residents' stay.
Resident Rights Not Reviewed or Posted Current
Penalty
Summary
The facility failed to ensure the resident bill of rights were provided verbally and in writing for all residents. During review of Resident Council Minutes Forms for 2/24/26, 3/26/26, and 4/16/26, the minutes did not document that the resident rights were reviewed. When seven residents attended a resident council meeting held by the surveyor, the residents stated the rights had not been reviewed. One resident said the rights were given at admission and posted in the facility, while another resident said they had been admitted years ago and were not coherent at that time. At 11:45 a.m., the poster near the nurses' station was reviewed and was dated 9/19, not the current 12/25 resident rights poster. During interview, the administrator stated the life enrichment supervisor was responsible for the resident council meetings and verified that the resident rights were not reviewed during those meetings and that the poster was not current. The facility policy for Resident and Family Council stated the facility would provide meeting space, inform residents of meeting opportunities, and respond to council concerns, but it did not include review of resident rights in the agenda.
Failure to Provide Resident Rights Notice at Admission
Penalty
Summary
The facility failed to inform a resident, both orally and in writing in a language the resident understands, of her rights and all rules and regulations governing resident conduct and responsibilities during her stay. Review of the resident’s record showed no signed acknowledgment that she was informed of her rights and responsibilities prior to or at admission. The resident was admitted with diagnoses including major depression, heart failure, pulmonary hypertension, and dementia, and was observed lying in bed, alert, and oriented to name and place. She stated she did not know she was not receiving her major depression medication until her daughter informed her, and she reported no interest in activities because she was depressed. The resident’s responsible party stated the resident’s behavior was not normal, describing refusal of meals, waking at night, and loss of interest in everything. She said she discovered the resident was not taking Lexapro after requesting the medication list and stated the facility did not notify her before discontinuing the medication. She also stated she did not receive notice of rights and services during admission in oral or written form and had not signed admission documents. The administrator stated there was no evidence the resident was provided written information regarding resident rights on admission or after, that the facility did not have an admission packet for the resident, and that the packet could not be found.
Failure to Review Resident Rights
Penalty
Summary
The facility failed to periodically inform residents of their rights after admission for 7 of 7 sampled residents (Residents 7, 20, 35, 40, 49, 67, and 75) reviewed for resident rights. During a resident council meeting on 04/28/2026 at 2:07 PM, all seven residents stated that staff did not talk about or review resident rights in the facility, and they said resident rights were not reviewed at resident council meetings. Review of resident council meeting minutes from November 2025 through April 2026 showed no documentation or confirmation that resident rights were reviewed. In an interview on 04/30/2026 at 3:17 PM, the Administrator stated they did not know whether resident rights were routinely reviewed with residents in resident council or otherwise.
Failure to Review Resident Rights in Council Meetings
Penalty
Summary
The facility failed to provide ongoing communication to residents about their rights through resident council meetings for 4 of 4 cognitively intact residents who attended those meetings. Quarterly MDS assessments for R33, R34, R14, and R24 indicated each resident was cognitively intact. However, resident council meeting minutes from November 2025 through April 2026 did not show that resident rights were reviewed or discussed during the meetings. During a resident council meeting on 4/30/26, R33, R34, R14, and R24 stated they regularly attended the meetings and did not recall any time when resident rights had been discussed. All four residents stated they did not know where resident rights were posted in the facility, although a resident rights poster was hung in a hallway across from the beauty salon. The life enrichment director stated she took minutes for resident council meetings and described the usual meeting format, but she could not find documentation showing resident rights were discussed. The administrator stated resident rights were reviewed upon admission and said that if social workers attended resident council, they would be responsible for reviewing resident rights, adding that the facility was working on standardizing this process.
Failure to Provide Written Admission Agreement and Cost Information
Penalty
Summary
The facility failed to provide a signed admission Agreement that included a written notice of resident rights, services, and charges for one resident. Record review showed that this resident was admitted following a hospital stay, but the resident’s file did not contain any signed admission Agreement. During a side‑by‑side record review and interview, the Director of Guest Services described the usual process for obtaining a signed admission Agreement, which involved assessing the resident’s cognition or checking a BIMS score, then reviewing and signing the Agreement with the resident if cognitively intact, or with a POA, spouse, or other family member if not. She stated this was typically completed within about 72 hours, depending on family availability, and that the Agreement could be executed via electronic signature. A blank admission Agreement reviewed during the survey did not have prices for non‑covered services filled in, and the Director of Guest Services explained that when she populated the form with the date, the prices and costs of services would automatically populate. When asked to locate the signed admission Agreement for this resident, the Director of Guest Services searched the EMR and confirmed there was none, stating she did not know what happened but recalled she was the only person in Guest Services at the time and had taken a vacation during that period. When questioned about written notice of costs for services not covered once the resident’s benefits ended, the Director of Guest Services stated that the resident or representative would have had a conversation with the Business Office Manager (BOM) and/or Social Services Director (SSD). In a separate interview, the BOM and SSD stated that written information about room rates and non‑covered costs was contained in the admission Agreement and acknowledged that, for this resident, they had only verbal conversations with the resident and her daughter about costs, with no documentation of written notice.
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