Deficiency in Resident Visitation Rights Due to Visitor Limitation Policy
Penalty
Summary
Surveyors identified a deficiency related to the facility's failure to respect residents' rights to receive visitors without limitation. Reception staff reported and signage indicated a policy limiting visitors to two per resident per visit, a practice that had been in place for several years. Observations confirmed the presence of this signage at the receptionist's desk, and interviews with staff and family members corroborated that this visitor limit was communicated and enforced, despite the facility's own policy encouraging visiting by family and friends. A family member reported awareness of the two-visitor guideline but noted that the facility did not consistently enforce it, as evidenced by a group celebration for a resident's birthday. On another occasion, the visitor limit sign was not posted at the receptionist's desk, and staff could not account for its absence. A resident also stated that their family had been informed of the two-person visitor limit, indicating that the restriction was communicated to residents and their families. Interviews with the Social Service Director and the Administrator revealed that both were aware residents have the right to unlimited visitors and acknowledged that the signage was incorrect. They stated that alternative spaces, such as the patio or activity room, could be used if resident rooms became overcrowded, rather than limiting visitor numbers. The facility's written policy supported the right to visitation and the provision of comfortable visiting areas, but the observed and reported practices did not align with this policy.
Plan Of Correction
F 550 Immediate Corrective Action The signage at the receptionist desk was immediately removed. On 7/9/25, the Administrator gave a 1-1 in-service to Receptionist 1 and Receptionist 2 regarding the policy for resident rights, specifically regarding visitation. Identification of Others at Risk Social Services Director visited with residents on 7/10/25 to ensure they are able to have visitors with no restrictions. No other residents were identified with the same deficient. Process to Prevent Recurrence On 7/9/25, the DSD gave an in-service to staff regarding the policy for resident rights, specifically regarding visitation. The Social Service designee will visit residents randomly weekly for six weeks to discuss whether they had any concerns with visitation. All findings will be reported to the Administrator. Monitoring Performance The Activity Designee will discuss monthly at resident council for three months whether residents had any concerns with visitation. All findings will be reported to the Administrator. Findings will be reported to the QA committee for further review and recommendations, monthly, for 3 months or until substantial compliance is achieved. The Social Service designee will visit residents randomly weekly for six weeks to discuss whether they had any concerns with visitation. All findings will be reported to the Administrator. Monitoring Performance The Activity Designee will discuss monthly at resident council for three months whether residents had any concerns with visitation. All findings will be reported to the Administrator. Findings will be reported to the QA committee for further review and recommendations, monthly, for 3 months or until substantial compliance is achieved.