Failure to Offer Resident Choice During Shower Resulting in Psychological Distress
Summary
Staff failed to honor a resident's right to self-determination and choice regarding personal care. On the morning of 3/21/25, two CNAs entered the room of a resident with spinal stenosis and discogenic pain and informed her she would be receiving a shower, without offering her a choice or seeking her consent. During the transfer from bed to shower, the resident experienced incontinence, requiring her to be cleaned and then placed in a Hoyer lift for transfer to the shower chair. The resident reported feeling upset and embarrassed during the incident, especially as the CNAs argued about operating the lift. A roommate, who was cognitively intact, witnessed the event and described the resident being yanked from bed and hoisted up. Interviews with staff confirmed that the resident was alert, oriented, and capable of expressing her preferences, and that it was important to explain care procedures to her beforehand. The Social Service Director also confirmed a complaint from the resident's son regarding the incident. Facility policy requires that residents be informed in advance of care, have the right to refuse or discontinue treatment, and that staff are educated on resident rights, including the right to choose schedules and activities. Despite these policies, the resident was not given the opportunity to exercise her right to refuse or choose her care at the time of the incident.
Penalty
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The facility failed to consistently honor resident preferences and care‑planned frequency for bathing, resulting in multiple residents going six to ten days or longer between baths despite being scheduled for twice‑weekly showers or baths. Several residents, including those with impaired and intact cognition, reported missed or inconsistent baths, needing to repeatedly remind CNAs, and being told they were skipped due to other residents waiting longer, staffing shortages, or equipment issues. Observations included a resident with long, jagged fingernails and urine odor who reported missed scheduled showers. Review of EMRs and the bath schedule showed numerous missed baths without documented refusals or valid reasons, while the grievance log and resident council minutes documented ongoing complaints from multiple residents about not receiving baths as scheduled. Nursing staff acknowledged receiving complaints and that residents sometimes went more than a week without bathing, despite a facility policy stating residents have the right to choose timing and frequency of bathing and requiring documentation of bathing activity or refusals.
The facility restricted cognitively intact residents on an upper floor from independently accessing the first floor and outdoor patio by using an elevator keypad code not shared with residents and a locked exterior patio door, requiring staff supervision for any movement off the unit. Three residents with diagnoses including anxiety, depression, vitamin D deficiency, heart failure, chronic pain, Parkinson’s disease, and psoriatic arthritis reported feeling like they were in a prison and expressed a strong desire to go outside for fresh air and to access common areas such as the lobby and aquarium. MDS assessments and care plans documented that it was very important for these residents to go outside when weather permitted and that they enjoyed outdoor time, yet the monthly activities calendar lacked outdoor activities. The AD and DON stated that residents could only go outside when staff were available to accompany them, citing corporate direction, elopement concerns for other residents, and a prior elopement, while the Administrator confirmed there was no specific policy for securing the floor or for residents going outside, despite a Resident Rights policy requiring that residents be able to exercise their rights without interference.
A resident’s motorized wheelchair remained nonfunctional for an extended period despite vendor measurements and an approved authorization, limiting the resident’s mobility and independence. The PT director had a vendor assess the resident and forwarded the estimate to the Administrator during a period when there was no BOM. The BOM, who started later, learned that payer authorization had already been granted, but the facility had not tracked or followed up on the process, and the Administrator acknowledged a breakdown in follow-up and communication with the resident regarding the status of the wheelchair.
Surveyors found that the facility failed to honor resident mealtime and dining location preferences when multiple residents reported that the main dining room was frequently closed and never open on weekends, despite their desire to eat there to socialize and receive warm, complete meals. Residents stated that when they were served in their rooms, items they had selected on weekly menus were often missing, and soup and salad routinely offered in the dining room were not provided. The DON indicated that the Dining Manager (DM) decided when the dining room was open, and the DM acknowledged the dining room had been closed for several days due to equipment issues and remained closed on weekends as part of a post-COVID "plan" without an official written reopening plan. These practices conflicted with facility policies requiring support of resident choice regarding dining location and affirming residents’ freedom of choice in how they live and receive care.
The facility failed to honor resident self-determination when a memory care unit day room, which included a sensory room and bathrooms, was closed for heating repairs and all residents were moved to the dining room for leisure time. Over a weekend, 20 cognitively impaired residents, including individuals with Alzheimer's dementia, dementia, anxiety disorder, chronic kidney disease, and hypertension, experienced a disruption in their usual routine and loss of access to the sensory room. Families and resident representatives, who typically participate in care planning for these severely cognitively impaired residents, were not notified in advance or involved in deciding how residents would spend their leisure time, and some residents became upset and distraught by the change.
A resident with multiple chronic conditions and documented preference for showers was placed on transmission-based precautions for COVID-19. After receiving one shower, the resident repeatedly requested additional showers but was told that showers were limited to a specific shower day and that bed baths would be provided during isolation. Over several days, the resident complained of feeling dirty and not being allowed to shower, receiving only partial and complete bed baths until a later date when a shower was finally provided. The DON acknowledged that facility policy is to allow showers upon request even during isolation, and the CNA supervisor stated that if a shower was requested, it should have been provided.
Failure to Honor Resident Bathing Preferences and Scheduled Bathing Frequency
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to honor residents’ rights to choose and receive bathing at the frequency specified in their care plans and preferences. Multiple residents who preferred bathing at least twice weekly did not consistently receive baths or showers as scheduled, and staff did not consistently document refusals or reasons for missed baths. For one resident with severely impaired cognition, the care plan dated 3/25/26 indicated a preference for two baths per week, yet electronic records from 1/28/26 through 3/25/26 showed she received a bath on 3/9/26 and 3/16/26, refused on 3/13/26, was marked as “not available” on 3/20/26 without any supporting documentation that she was out of the facility, and had no documentation of being offered or receiving a bath on 3/23/26. A family member reported concerns that this resident had only received one shower since admission and raised these concerns to the administrator. Another resident with moderately impaired cognition had a care plan dated 3/25/26 indicating a preference for two baths per week. The bath schedule showed he was to receive baths or showers twice weekly on specific days, and there was no documentation of refusals. However, bathing records from 1/28/26 through 3/25/26 showed gaps of six and seven days between some baths, including a seven‑day interval before a bath on 2/21/26 and a six‑day interval before a bath on 3/13/26. This resident reported that there were times he did not receive a bath for a week, that he had to repeatedly remind staff to get a bath, and that the days he was bathed were inconsistent, sometimes occurring every other day and other times with a week between baths. A cognitively intact resident with a care plan preference for two baths per week was scheduled for baths on two specific days each week, but bathing documentation showed missed baths on multiple dates with no refusals recorded. As a result, there were intervals of seven and ten days between baths. This resident stated he did not receive the showers he was supposed to and was unsure if he would receive a scheduled shower on the day of interview. Another resident with moderately impaired cognition, whose care plan indicated a preference for two to three showers per week and who was scheduled for showers on Sundays and Thursdays, had multiple missed showers without documented refusals and repeated six‑day gaps between bathing. During observation and interview, this resident had long, jagged fingernails, smelled of urine, and reported that showers were sometimes not provided on scheduled days or were changed, and that staff had told him he would not get a shower because the shower was being repaired. The facility’s own bath schedule listed specific days for each of these residents to receive baths or showers, but documentation and resident interviews showed that these schedules were not consistently followed. The grievance log from November 2025 through March 2026 recorded multiple resident complaints and resident council concerns about not receiving baths or showers as expected, including reports from several residents that they had gone extended periods without bathing and that staff told them they were being skipped because other residents had waited longer or due to staffing issues. During a resident council interview, several residents reiterated that baths were not completed as scheduled and described waiting from eight days up to three weeks between baths, as well as equipment issues such as a broken chair that prevented bathing. Nursing staff, including an RN and a restorative aide, acknowledged receiving complaints that residents were not getting baths as scheduled and stated that residents sometimes went more than a week without a bath, and that missed baths could contribute to odors, dignity concerns, and skin conditions. The DON stated she expected residents to be bathed according to their care plan preferences and that refusals should be documented, but she was aware of prior grievances about missed baths. The facility’s bathing policy stated that residents have the right to choose the timing and frequency of bathing and required documentation of bathing activity or refusals and reapproach after refusals, but the documented patterns and interviews showed that these requirements were not consistently met.
Failure to Honor Cognitively Intact Residents’ Right to Free Movement and Outdoor Access
Penalty
Summary
The facility failed to honor residents' rights to self-determination and freedom of movement by restricting cognitively intact residents from independently accessing other areas of the building and the outdoors. During a Resident Council group interview, three residents living on the third floor reported they were prohibited from going to the first floor or the outdoor patio without staff supervision. Barriers included an elevator that required a keypad code, which was not shared with residents, and a locked exterior door to the patio. These restrictions prevented them from visiting common areas such as the first-floor aquarium, the lobby, and the outdoor seating area at will; one resident reported being prevented from going to the lobby to collect cups for coffee the previous evening. All three residents expressed a desire for independent access to facility amenities and the outdoors and stated the facility felt like a prison. Record review showed that each of the three residents was assessed as cognitively intact and without hallucinations, delusions, or behavioral issues. One resident had diagnoses of anxiety, depression, and vitamin D deficiency, and her MDS indicated it was very important for her to go outside for fresh air when weather permitted. Another resident had anxiety, vitamin D deficiency, and psoriatic arthritis, was able to transfer independently in her wheelchair, and her MDS also indicated it was very important for her to go outside for fresh air when weather permitted. The third resident had type 2 diabetes, insomnia, heart failure, chronic pain, and Parkinson's disease, was able to transfer independently in his wheelchair, and his MDS likewise documented that it was very important for him to go outside for fresh air when weather permitted. Care plans for all three residents documented that they enjoyed going outside in good weather and were to participate in activities of their choice, with assistance or reminders as needed. However, the March activities calendar for the third floor contained no scheduled outdoor activities. The AD stated that residents could go outside only when weather permitted and when a staff member was available to accompany them, and that some residents would be fine to go outside unsupervised but corporate required supervision. The DON confirmed that third-floor residents were not given the elevator code because some residents on that floor were elopement risks, that the outside patio door was locked due to a past elopement, and that aides did not have time to take residents downstairs or outside, so they were to contact the AD to do so. The Administrator acknowledged there was no policy for keeping the third floor secured, that residents were not allowed to have the elevator code, that residents had to be supervised to go outside, and that there was no policy for residents going outside, despite a facility Resident Rights policy stating residents must be able to exercise their rights without interference, coercion, discrimination, or reprisal.
Failure to Provide Timely Motorized Wheelchair to Support Resident Independence
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to self-determination and freedom of movement by not providing a functional motorized wheelchair in a timely manner. A resident reported during the complaint investigation that their motorized wheelchair had been nonfunctional since 2025. The resident stated that a vendor had come to complete measurements for repair or replacement, but there had been no follow-up or communication regarding the status of the equipment. The resident reported that the lack of a functioning motorized wheelchair limited their mobility within the facility and affected their independence. Record review and staff interviews showed that the Physical Therapy Director had the resident measured for a motorized wheelchair by Freedom Mobility on 08/18/2025 and forwarded the vendor’s estimate to the Administrator because there was no Business Office Manager (BOM) in place at that time. The BOM, who started in December 2025, stated she became aware of the wheelchair issue on 01/16/2026 and learned from Freedom Mobility that authorization from Telligen had been received on 10/10/2025. The Administrator confirmed that from July 2025 through December 2025 there was no BOM and she had assumed Business Office responsibilities, which led to a breakdown in follow-up and tracking of the authorization process. She acknowledged that the facility did not follow up on the approved request and did not update the resident on the status, resulting in a delay in providing the necessary mobility equipment.
Failure to Honor Resident Mealtime and Dining Location Preferences
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ mealtime preferences and support resident choice regarding dining location and meal service. During an observation of the main dining room, surveyors noted residents interacting and staff taking meal orders in a restaurant-style format. However, in a confidential meeting with eight residents who usually attended resident council, six reported that the main dining room was frequently closed and not open at all on weekends. These residents stated they preferred eating in the dining room because it allowed them to get out of their rooms, socialize, receive warm meals, and obtain all menu items they had selected. They reported that when they received meal trays in their rooms during dining room closures, items were often missing despite their pre-completed weekly menu selections, and that soup and salad routinely offered in the dining room were not offered when they ate in their rooms. Residents reported that these dining restrictions had been in place for a long time and expressed frustration over their loss of choice to eat in the main dining room, with several stating they believed the dining room was only opened that week because the State Agency was present. The DON stated that decisions about opening or closing the main dining room were made by the Dining Manager (DM). The DM reported that the dining room would only close for emergencies such as an outbreak, but also acknowledged it had been closed for four or five days earlier in the month due to a fuse box issue with the dish machine. The DM further stated the main dining room was not open on weekends, explaining this was their plan since COVID-related dining room shutdowns, and that there was no official written plan for reopening. These practices conflicted with facility policies stating that residents would be interviewed about their preference to eat in the dining room or their room and that residents have freedom of choice, to the maximum extent possible, about how they wish to live their everyday lives and receive care.
Failure to Involve Cognitively Impaired Residents and Representatives in Leisure-Time Changes During Unit Repairs
Penalty
Summary
The facility failed to honor residents' rights to self-determination and participation in planning of care and services when repairs were conducted on the Fair Haven Unit day room, which included a sensory room and two bathrooms. On 03/06/2026, the Deputy Administrator became aware of a malfunctioning heater in the Fair Haven day room and directed staff to relocate all 20 residents of the unit, including residents with severe cognitive impairment, to the dining room for leisure time on 03/07/2026 and 03/08/2026. Activities and a television were brought into the dining room, but residents were kept there for their leisure time before and after lunch and dinner, resulting in a disruption of their usual daily routine and how they typically spent their leisure time. The Fair Haven Unit is a memory care unit with residents who have impaired cognitive abilities, including residents diagnosed with Alzheimer's dementia, dementia, anxiety disorder, chronic kidney disease, and hypertension. Minimum Data Set assessments documented that several residents were severely cognitively impaired and had family or significant others participate in their assessments. Despite this, there was no documented evidence that resident representatives were notified in advance or involved in choosing how the residents would spend their leisure time during the repairs. A grievance dated 03/09/2026 indicated concerns that residents had been kept in the dining room over the weekend, and a resident representative reported that some residents were upset and distraught by the disruption, noting that the alternatives did not include access to a de-escalation area such as the sensory room. The Deputy Administrator acknowledged that families and representatives were not informed prior to the change in routine and that residents and their representatives were unable to choose how leisure time was spent during the affected days.
Failure to Honor Resident Bathing Preferences During Isolation
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to choice regarding bathing preferences while on transmission-based precautions for COVID-19. The resident was admitted with multiple diagnoses including type 2 diabetes, a personal history of COVID-19, hypertension, peripheral vascular disease, and chronic pressure ulcers of both heels. The resident’s baseline care plan documented a preference for showers rather than bed baths. The electronic health record showed the resident tested positive for COVID-19 and was placed on isolation precautions. Progress notes indicated the resident received a shower on 01/14/26, then later complained on 01/16/26 about not being able to shower due to being in isolation. The resident again requested a shower on 01/17/26 and was told by staff that the shower day was on Tuesdays. Further record review showed that on 01/19/26 the resident was upset about not being able to shower, stating they felt dirty and needed a shower. On that date, the resident received a partial bed bath in the early morning and a complete bed bath in the afternoon, and did not receive a shower until 01/20/26. The DON stated that residents are informed at the time isolation is initiated that bed baths will be given instead of showers, but also stated that it is policy to allow residents to shower when they ask, even while in isolation, and confirmed that going five days without a shower when a resident is requesting one does not meet her expectations. The CNA supervisor reported not recalling being notified that the resident was upset about not being allowed to shower while in isolation and stated that if the resident requested a shower, the resident should have been showered.
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