Failure to Establish Resident Rights Compliance Structure
Summary
The facility failed to establish a structure to comply with the resident's right to contact external entities, as required by federal regulations. During the survey, it was discovered that no personnel were assigned to monitor compliance with resident rights. Additionally, the resident rights policy and procedure were found to be hospital-based, bearing the logo of Episcopal Hospital San [NAME] Metro, rather than being tailored to the specific needs of the facility. The policy was a 13-page document that included all 483.10 resident rights statements in one policy, but lacked individualized mechanisms to ensure compliance with CMS Medicare requirements.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident’s family member reported that a GNA told her that residents and their representatives were not allowed to speak directly with state surveyors who were on site. Instead of bringing the family member to a surveyor, the GNA provided contact information for the state oversight agency to file a complaint. The family member subsequently filed a complaint, and record review confirmed the complaint submission, demonstrating that the resident’s representative was discouraged from and not permitted to communicate directly with surveyors.
An independent liaison, not affiliated with the facility or hospice, accessed and retained a resident's medical records without consent or proper authorization. The liaison did not meet with the resident or obtain consent, and used information from the records to arrange a discharge to hospice care. The resident had a terminal prognosis and intact decision-making capacity. Facility policy required limiting access to PHI, but this was not followed, resulting in a HIPAA violation.
Facility staff failed to protect a resident from sexual abuse and harassment by another resident, discouraged the victim from contacting police, and did not report the incident to authorities as required. Staff did not conduct a comprehensive investigation, omitted key witness interviews, and failed to follow abuse reporting policies, resulting in delayed and incomplete documentation of the event.
A resident with cognitive impairment was discouraged by facility staff from speaking with a state surveyor, violating residents' rights. The resident, who wished to leave the Memory Care unit for outdoor activities, was told by an unnamed staff member not to talk to surveyors as it could cause trouble for the facility. The facility's administration acknowledged awareness of the rule against discouraging resident communication with surveyors.
A facility failed to ensure a resident could communicate with their county care coordinator (CC), resulting in multiple unsuccessful contact attempts by the CC. The social services designee (SSD) instructed the CC to direct communication needs to her, but the CC faced difficulties reaching the SSD and the resident was not informed of the calls. Interviews revealed no directive to forward calls to the SSD, and residents could take calls privately. The resident was unaware of the CC's attempts, indicating a communication breakdown.
Resident Representative Discouraged From Speaking Directly With State Surveyors
Penalty
Summary
The facility failed to permit a resident’s representative to speak directly with state surveyors during a recertification survey. During an interview, the family member of Resident #14 reported that a Geriatric Nursing Assistant (GNA #23) told her that residents and their representatives were not allowed to speak directly with state surveyors who were on site. Instead of facilitating contact with the surveyors, GNA #23 provided the family member with contact information for the Office of Health Care Quality (OHCQ) to file a complaint. Complaint record review confirmed that the family member subsequently filed a complaint with OHCQ. This conduct resulted in the resident’s representative being discouraged from and not permitted to communicate directly with the state surveyors who were present in the facility. No additional medical history or clinical condition for the resident was provided in the report.
Unauthorized Access and Disclosure of Resident Medical Records
Penalty
Summary
A deficiency occurred when an independent liaison, who was not an employee of the facility or the hospice company, obtained and retained medical records for a resident without proper authorization or consent. The liaison stated she did not meet with the resident or the resident's sister prior to arranging the discharge and did not receive the resident's consent to access or review the medical records. The liaison acquired the records from the hospice company and used information from them to facilitate the resident's discharge, despite not having a medical background or a direct relationship with the facility or hospice. The resident involved had a history of paraplegia, essential hypertension, and recurrent urinary tract infections with sepsis, and was readmitted to the facility with a terminal prognosis. The resident's medical records indicated intact cognition and the capacity to make medical decisions. The discharge summary and care plan noted the resident's terminal condition and the plan for a safe transition home, but there was no documentation that the physician spoke to the resident's family about the terminal prognosis. The discharge planning review form was also found to be incomplete. Facility policy required that access to protected health information (PHI) be limited to the minimum necessary and that the entire medical record should not be disclosed unless specifically justified, particularly for non-treatment purposes. The liaison's access and retention of the resident's medical records, without proper consent or justification, constituted a violation of the Health Insurance Portability and Accountability Act (HIPAA) and the facility's own policies regarding the disclosure of PHI.
Failure to Protect Resident and Report Sexual Abuse Allegation
Penalty
Summary
Facility staff discouraged a resident from communicating with external local entities, including the police, during an abuse allegation, and failed to allow evidence from a police report in the investigation of a sexual abuse situation involving two residents. The incident involved a resident with a traumatic brain injury and no cognitive impairment, who was sexually harassed and assaulted by his roommate, a resident with a history of drug and alcohol abuse. Despite the victim's immediate report to staff and requests from both the resident and his spouse for police involvement, facility staff did not notify law enforcement or Adult Protective Services (APS) as required. The facility's documentation and staff interviews revealed that the abuse was witnessed by staff, but the administration failed to initiate a comprehensive investigation or report the incident to the state agency within the mandated timeframe. The facility's own abuse policy required police involvement when a crime was alleged, but this was not followed. Additionally, the facility failed to conduct required staff training and background checks, and did not provide adequate protection or supervision to prevent further abuse. The initial facility report was incomplete, contained inaccuracies, and was only produced after surveyors requested documentation several days after the incident. Further review showed that the facility did not interview all relevant parties, including staff witnesses, the victim's spouse, or other residents who may have been affected. The facility's failure to implement its abuse policies resulted in the lack of protection for the victim and inadequate investigation and reporting of the abuse. The state agency ultimately found the abuse to be substantiated, at least in part, based on the evidence provided.
Resident Discouraged from Communicating with Surveyor
Penalty
Summary
The facility staff prohibited and discouraged a resident from communicating with a state surveyor, which is a violation of residents' rights. The incident involved a resident who was admitted to the facility with diagnoses including end-stage renal disease requiring hemodialysis, dementia, and atrial fibrillation. The resident, who was cognitively impaired with a BIMS score of 11, expressed a desire to leave the Memory Care unit to enjoy outdoor activities. However, the care plan did not include interventions to facilitate outdoor access, focusing instead on encouraging participation in indoor activities. During an interview, the resident reported being told by an unnamed staff member that he should not speak to surveyors because he had already disclosed too much information, which could cause trouble for the facility. This interaction was confirmed during a final interview with the facility's administration and corporate nurse consultants, who acknowledged awareness of the rule that residents should not be discouraged from speaking with surveyors.
Failure to Facilitate Resident Communication with Care Coordinator
Penalty
Summary
The facility failed to ensure that a resident was provided with communication access to their county care coordinator (CC) and did not discourage or obstruct these communications. The CC made multiple attempts to contact the resident, R18, without success. On one occasion, the CC left contact information with an unidentified charge nurse, but the resident was not informed of the call. The social services designee (SSD) instructed the CC to direct all communication needs to her, citing the nurses' busy schedules. Despite this, the CC experienced difficulty reaching the SSD and was unable to contact R18, leading to a personal visit to the facility. During this visit, R18 reported not receiving any messages from the CC, indicating a breakdown in communication. Interviews with facility staff, including a trained medication aid (TMA) and a licensed practical nurse (LPN), revealed that there was no directive to forward calls to the SSD, and residents could take calls in a private room. The SSD confirmed that residents had the right to receive phone calls and that calls could be forwarded to her if necessary. However, the CC's repeated attempts to contact R18 were unsuccessful, and the resident was unaware of the attempts made to reach him. This situation suggests a failure in the facility's communication process, preventing the resident from accessing necessary services.
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.
