Resident Placed on Secured Unit Without Required Authorization or Consent
Summary
The facility failed to ensure that a resident placed on a secured behavioral unit met the established criteria for admission to that unit. Specifically, the resident had diagnoses including subdural hemorrhage, intracranial injury, hypotension, generalized anxiety disorder, and impaired cognition, and was identified as being at risk for elopement and wandering. The care plan indicated the resident resided on the secure unit for safety, with interventions to manage wandering behaviors. However, there was no physician order authorizing the resident's placement on the secured unit, and the resident had not signed a consent form for this placement. Further review revealed that the resident had not been declared incompetent, nor did they have a power of attorney or guardian. The facility's policy required that residents admitted to the secure behavioral unit must have a current mental health diagnosis, psychosocial or behavioral disturbance, be deemed incompetent by a physician, and have a current or active power of attorney or guardian. These requirements were not met in this case, as confirmed by staff interview and medical record review.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A facility disenrolled three residents and attempted to disenroll a fourth from Managed Medicare without clear resident or representative request, consent, or understanding. Staff told representatives that switching to traditional Medicare would improve coverage or therapy access in the SNF and that residents could switch back after discharge. Records showed no signed consent forms or other documentation supporting the plan changes, and the facility lacked written policies for assisting with coverage changes.
Two residents with ESRD were admitted and retained while receiving PD even though the facility did not have PD listed in its facility assessment or an approved PD program. Records showed nightly PD orders and treatment logs, and family members stated the facility provided PD daily and did not tell them it lacked the license to do so. The ADM stated nursing staff assisted with PD initiation and disconnection, while the DON stated the residents should not have been admitted for PD care.
Surveyors found that the facility’s admission and valuables policies contained language stating the facility would not be responsible for resident money or personal items above a set dollar amount and would not be liable for lost or stolen items except in limited circumstances, effectively requiring residents or their representatives to waive facility liability for personal belongings. Review of records for two residents showed that, although admission agreements were properly signed, required Resident Inventory Listing forms were not completed, contrary to the facility’s own personal property policy. The administrator reported that the staff member responsible for inventories had left and not been replaced and stated that corporate legal guidance was that the facility was not required to replace stolen or missing items, with replacement handled only on a case-by-case basis.
Admission agreement signed without confirmed capacity. A resident with dementia, moderate cognitive impairment on BIMS, and pre-admission concerns for worsening cognition, poor self-care, and frequent falls signed his own admission paperwork. The record did not show attempts to contact his HC POA before the signature, and staff later acknowledged the resident was confused and that a psych note described cognitive deficits and memory gaps requiring POA support.
Missing Required Admission Documentation: The facility failed to maintain required written admission information for a cognitively intact resident admitted with cervical myelopathy and generalized muscle weakness. The record lacked evidence that the resident and/or resident representative received and acknowledged key admission materials, including patient portion liability, daily rate cost structure, resident rights, appeal rights, consent to treatment, ancillary service choices, bed hold policy, and consequences for nonpayment. The NHA confirmed admission paperwork should be reviewed on admission, but documentation for this resident was not present.
A resident admitted with diverticulosis and a cognitive communication deficit did not receive required admission documents at or before admission. The admissions packet was generated but later found unsigned and was only sent by certified mail after the resident had already discharged. The resident’s family confirmed the documents were received post-discharge. The Admissions Director acknowledged that some residents had not been given admission documents upon admission and that he mailed them later, citing frequent turnover in the admissions role. The DNS stated she expected admission documents to be provided timely.
Unauthorized Medicare Plan Changes
Penalty
Summary
The facility failed to protect 4 of 4 residents’ rights to Medicare benefits by disenrolling three residents and attempting to disenroll a fourth from Medicare Managed Health Plans without their request, consent, knowledge, or complete understanding. The report states the facility also failed to develop written policies and procedures for assisting beneficiaries with changing health care coverage, including when the facility could assist with a plan change and the need for an attestation signed by the staff member who assisted with the enrollment change. For one resident, the representative said facility social services staff told them it was better to be on traditional Medicare while in the SNF and that the resident would be transferred back to Managed Medicare after discharge. The representative later received a letter from the Managed Medicare plan stating the resident had been disenrolled. A physician also stated the representative came in tears after being told by facility staff to disenroll from Managed Medicare and switch to traditional Medicare, then re-enroll later. For two other residents, representatives stated facility staff approached them about changing coverage and told them traditional Medicare would cover more therapy or that the resident could switch back after discharge. One resident said they did not know whether they consented, and the representative said they were not aware of the disenrollment until after it occurred. For the fourth resident, the resident stated the Managed Medicare plan notified the facility that coverage was ending and facility staff discussed a secondary insurance option, while the business office manager said the facility tried to assist the resident to switch to traditional Medicare. Review of the records showed no consent forms or other documentation supporting that the residents or representatives requested the changes.
Admission and retention of residents requiring PD without approved PD services
Penalty
Summary
The facility failed to ensure that two sampled residents received services in accordance with the facility’s capabilities and available resources when it admitted and retained residents who required peritoneal dialysis (PD) without having an established PD program and the necessary services to safely provide PD care as approved by the State Agency. The deficiency was identified through interview and record review and involved Resident 1 and Resident 2, both of whom had end stage renal disease (ESRD) and were receiving PD while residing in the facility. Resident 1 was admitted with ESRD and infection and inflammatory reaction due to PD. Records showed Resident 1 had the capacity to understand and make decisions and was receiving PD for ESRD. Orders documented PD treatments using Dianeal with 1.5% Dextrose and later 1.5% Dextrose Solution, followed by Extraneal, with nightly treatments beginning at 7 PM. Treatment logs and the MAR showed PD treatments were provided across multiple periods during the resident’s stay. Resident 2 was admitted with ESRD and dependence on renal dialysis. Records showed Resident 2 had intact cognitive skills and was receiving PD upon admission. Orders documented PD using 2.5% Dextrose solution with nightly treatments beginning at 7 PM, and the MAR and treatment records showed PD treatments were provided during the resident’s stay. Family members stated the facility provided PD treatment every day and that they were not told the facility did not have the license to provide PD in the facility. Resident 1 stated she agreed to be admitted because she was told the facility could provide PD treatment and she did not know the facility was not allowed to provide PD. The facility assessment did not include PD services. The Administrator stated nursing staff assisted with initiating and disconnecting PD treatments and that the facility had the dialysis solutions and equipment on hand. The DON stated the facility should not have admitted the two PD residents and that providing PD service to them could put them at risk for infection and other complications. The facility policy required evaluation of the level of care needed prior to admission, and the CDPH guidance stated SNFs seeking to provide PD services must apply for approval of the optional service and notify CDPH before starting PD services.
Noncompliant Admission Liability Language and Missing Resident Property Inventories
Penalty
Summary
Facility staff failed to ensure that admission policies and documents complied with requirements regarding resident property and financial protections. Review of the facility’s undated "Cash and Valuables Policy Update" showed language stating the facility would not be responsible for any money or personal items exceeding a $40.00 limit. The admission agreement dated 02/2018 further stated the facility would not be liable for any resident items that were lost or stolen, except for items noted for replacement under state guidelines. These provisions effectively required residents and/or responsible parties to waive facility liability for loss or damage to personal belongings as a condition of admission, contrary to regulatory requirements that residents not be required to give up Medicare or Medicaid benefits or pay privately as a condition of admission, and that they be informed of what care the facility does not provide. In addition, the facility did not follow its own "Personal Property" policy dated 12/2024, which required that residents’ personal belongings and clothing be inventoried and documented upon admission and as items were replenished. Record review for two residents showed that, although admission agreements were signed and dated by the residents/responsible parties and a facility representative in April 2026, there was no documentation that staff completed a Resident Inventory Listing form for either resident. During an interview, the administrator stated that the staff person responsible for completing inventory lists had quit and had not been replaced, and acknowledged that inventory sheets for these residents could not be located. The administrator also reported that the corporate legal department advised that in Missouri the facility was not required to replace stolen or missing items, and that the policy stated the facility was not responsible for replacing missing or stolen items except on a case-by-case basis.
Admission Agreement Signed Without Confirmed Capacity
Penalty
Summary
The facility failed to ensure that one resident had the capacity to understand the terms of the admission agreement before signing it. Resident R64 was admitted with diagnoses including hypertension, hyperlipidemia, and dementia, and the admission MDS showed a BIMS score of 11, indicating moderate cognitive impairment. Pre-admission hospital documentation described the resident as a poor historian with cognitive impairment/dementia that was likely worsening, along with concerns about inability to care for self, frequent falls, balance problems, and not taking medications for months. The record showed that Resident R64's admission agreement was completed and signed by the resident, even though the clinical record did not include documentation that attempts were made to contact the resident's health care POA. The resident's POA was listed in the pre-admission paperwork and on the Durable Health Care POA document, but the facility did not document efforts to involve that representative before the resident signed the paperwork. A nursing note also described the resident as very confused and slightly agitated, and the social worker documented family concerns about the current POA's intentions and finances. During interview, the NHA stated the resident signed his own paperwork because no one was answering the phone and the family thought the POA was stealing his money. The NHA also stated that it took until December to get someone to evaluate the resident for capacity, and referenced a psychology note that said the resident had cognitive deficits and memory gaps and needed a POA to help with medical, financial, and other needs. Despite this, the facility allowed the resident to sign the admission agreement, and the NHA confirmed the facility failed to ensure the resident had the capacity to understand the terms of the admission agreement.
Missing Required Admission Documentation
Penalty
Summary
The facility failed to provide and maintain required written admission information and documentation for one of 17 residents reviewed, Resident 63. The facility policy titled Admissions Policy stated the facility would admit only individuals whose clinical, physical, psychosocial, and emotional needs could be met by the facility. The admission agreement reviewed included services, charges and fees, termination of the agreement, and miscellaneous areas to be reviewed with each newly admitted resident and/or resident representative, along with a signature page. Resident 63 was admitted with diagnoses including cervical myelopathy and generalized muscle weakness and was later discharged from the facility. The admission MDS dated January 5, 2026, showed the resident was cognitively intact with a BIMS score of 15 and that the resident and resident representative participated in the assessment process. However, the clinical record, including social service documentation and communication with the resident's family, did not contain documented evidence that required admission information was provided and acknowledged at admission. Missing documentation included written information regarding patient portion liability, daily rate cost structure, resident rights, appeal rights, consent to treatment, the right to choose ancillary services, bed hold policy, and consequences for failure to pay. The Nursing Home Administrator confirmed that admission paperwork is to be reviewed with each resident and/or resident representative upon admission, but no documented evidence was provided that this was completed for Resident 63.
Failure to Provide Admission Documents at or Before Admission
Penalty
Summary
The facility failed to ensure that a resident received required admission documents at or before admission, as required for resident rights and understanding of services. One resident admitted in October 2025 with diagnoses including diverticulosis and a cognitive communication deficit did not receive the admission packet at the time of admission. A certified mail receipt dated February 6, 2026, with a handwritten note showed that the admissions packet had originally been generated on October 30, 2025, but it was later discovered that it was not signed. The packet was subsequently sent to the resident by certified mail, and the resident’s family member confirmed that the admission documents were not received until after the resident had discharged from the facility. The Admissions Director stated he noticed that some residents had not received their admission documents upon admission and that he mailed the documents to those residents, also noting that many staff had been in the admissions position and some had been terminated or had quit. The DNS stated she expected staff to provide residents their admission documents in a timely manner.
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