Failure to Restrict and Monitor Visitor Access for Resident With Ongoing Substance Use Incidents
Summary
The deficiency involves the facility’s failure to implement and monitor its visitation and substance use disorder policies for a resident with a known history of psychoactive substance abuse and prior fentanyl overdose. The resident, who was cognitively intact but dependent on staff for transfers and with impaired mobility, had an active care plan for substance use that called for monitoring for signs and symptoms of substance use and abuse, such as confusion, drowsiness, outbursts of anger, and mood changes. Despite this, there was no documented evidence over multiple months that staff monitored the resident for these signs as outlined in the care plan. The facility’s visitation policy allowed for limiting or supervising visitors who abused, coerced, or exploited residents or who had a history of bringing illegal substances into the facility, but the facility did not operationalize these restrictions for this resident. Multiple documented incidents showed that the resident possessed or used substances and smoking materials, often in the presence of a specific family member visitor. On one occasion, staff observed the family member staying almost every night in the resident’s room and notified the DON and police due to suspicious behavior, but there was no documented investigation to determine the source of contraband. On another date, staff found the resident with vape devices and Blue Chew pills; these items were removed and given to a family member, and a late entry note by the DON recommended ongoing monitoring due to the resident’s substance-related history. However, there was no subsequent documentation that the resident was supervised or monitored for suspicious behaviors or signs of substance use as recommended. Later, staff documented that the resident’s room smelled like marijuana while the resident was with a visitor, and both were educated on facility policy, but the care plan was not revised to add new interventions related to this event. Further incidents continued without changes to visitation practices or documented monitoring. A restorative nursing assistant reported seeing the resident outside the facility with the same family member, who appeared to place an unknown smoking material to the resident’s mouth; this was reported to nursing and the administrator, and an order was obtained to closely monitor the resident for changes in level of consciousness, but there was no documentation that such monitoring occurred. Subsequently, the resident was found in his room vomiting, with foaming at the mouth and a smell of alcohol present; the family member at the bedside admitted giving the resident alcohol, and the resident was sent to the hospital and diagnosed with alcohol intoxication and alcohol abuse. When the resident returned from the hospital, there was no documentation that supervision or monitoring of the resident or the family member’s visits was implemented. Visitor sign-in records showed that the same family member and other friends continued to visit without restrictions or supervision. Interviews with the administrator, DON, nursing staff, and receptionist confirmed that no visitation restrictions or supervision were put in place for this family member, that there was no investigation into earlier contraband incidents, that the physician was not informed of key events, and that staff were not instructed on specific behaviors to monitor, despite the resident’s history and repeated episodes involving visitor-introduced substances.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Resident visitation rights not honored: A resident with depression, impaired cognition, and hospice care was not allowed to receive a family member’s visit unless a hospice nurse was present. The resident stated a desire to be visited, and RN and SSD interviews confirmed the visit restriction violated the resident’s right to visitors; the DON stated residents have the right to receive visitors of their choosing.
A resident with dementia, depression, anxiety, and severe cognitive impairment was denied visits and phone calls from family members she wanted to see. Staff told family members they could not visit or speak with her unless another family member approved it, and the resident later stated she wanted to see and talk with those relatives. Interviews showed staff were following the wishes of a family member with POA, while the resident's own preference was not honored.
Restriction of Room Visitation: The facility prohibited visitors from entering individual resident rooms and required visits to occur only in common areas. A family member reported being denied room visitation despite the resident’s preference for privacy and comfort, and surveyors observed the resident in bed with no clinical or safety reason preventing room visits. The Administrator and DON said the restriction was due to concerns about drugs being brought into the facility, but they could not provide documentation of current drug activity.
A resident with schizoaffective disorder, CVA, and Parkinson's disease had a BIMS score of 12 and needed supervision with toileting, transfers, and personal hygiene. She enjoyed family visits and wanted her sister to visit, but the Administrator banned the sister after an incident with staff despite no formal or legal restriction, and no accommodations were made even though the resident still wanted the visits.
Visitation Restriction Imposed Without Considering Resident Preference: A resident with hemiplegia, CVA, and DM was dependent for several ADLs and lacked decision-making capacity, yet she stated she wanted her son to keep visiting and denied being afraid of him. After an LVN reported witnessing the son pinch the resident's thigh, the facility limited his visits to common areas and the family room instead of her room, and the CCO stated the resident's visitation preferences were not fully considered before the restriction was imposed.
A cognitively intact resident with multiple chronic conditions was denied her preferred visitor after an incident during a bible study activity. The Activities Mgr and ED spoke with the resident's son, who was not her POA, and the son approved telling the friend she could no longer visit; staff then informed the friend without telling the resident. The resident later said she still wanted the friend to visit, and the DON confirmed the son was only the advocate and emergency contact.
Resident visitation rights not honored
Penalty
Summary
The facility failed to ensure that Resident 6’s right to receive visitors of his or her choosing was honored when the resident’s family member was not allowed to visit. Resident 6 was admitted with diagnoses including depression, malignant neoplasm of the endometrium, and hypertension. The history and physical indicated the resident lacked capacity to make and understand medical decisions, and the MDS showed moderately impaired cognitive skills and a need for substantial to maximal assistance with ADLs. Resident 6 was also under hospice care with an active order dated 4/8/2026. Facility documentation showed that on 6/1/2026, a progress note stated the family member was not allowed to visit Resident 6 without a hospice nurse present, and a social services note stated the family member was not allowed to come visit the resident. During interview, Resident 6 stated wanting to be visited by the family member. RN 1 stated the family member was not allowed to visit by the family member’s self and that this violated the resident’s right to visitors. The SSD stated the resident was not asked whether the family member should be allowed to visit and agreed that not allowing the visit when the resident wanted it violated the resident’s right to visitors. The DON stated the facility should allow all visitors per the resident’s will and that it is the resident’s right to receive visitors.
Resident denied chosen visitors and phone contact
Penalty
Summary
The facility failed to ensure Resident #2 had the right to receive visitors of her choosing and at the time of her choosing. Resident #2 was a female admitted and re-admitted with diagnoses including dementia, depression, and anxiety. Her admission MDS reflected severe cognitive impairment for daily decision making, and her care plan noted impaired cognition with behaviors and interventions to reduce distractions and use simple, direct communication. Record review and interviews showed that the facility did not allow Family Members F and G to visit or speak with Resident #2 when they called or came to the facility. Progress notes did not document any visitation limitations, but a 06/21/26 note by LVN C stated Family Member F wanted to talk to Resident #2 and was told she could not without Family Member E's approval. Family Member F reported she was denied a visit and a phone call and was not given a reason. Family Member G reported she was told by CNA A that she could not visit Resident #2 and was not given a reason, and she left after asking to speak with management. Interviews showed staff were acting on Family Member E's wishes, who said she had Medical Power of Attorney and did not want Resident #2 to have visits or calls from Family Members F and G because they stayed too long and upset Resident #2. LVN C and LVN B both stated they followed Family Member E's direction, while the resident herself later stated she wanted to see and talk to Family Members F and G. The Ombudsman also reported that Resident #2 said she wanted those family members to visit her, and the facility's physician, DON, and Administrator stated they were not aware of any restriction on those visits or calls.
Restriction of Room Visitation
Penalty
Summary
The facility failed to protect residents’ rights by restricting visitation in residents’ rooms. A posted notice at the front desk stated that, effective immediately, visitors would no longer be permitted in individual resident rooms and that visits had to occur in designated common areas such as the game room or front lobby. This restriction was identified during a complaint investigation involving one resident out of five reviewed. A family member reported that she had not been allowed to visit the resident in the resident’s room because the facility had discontinued room visitation, even though the resident preferred visits in the privacy and comfort of the room. During observation rounds, the resident was seen lying in bed, and no clinical, safety, or other factors were identified that would have prevented room visitation. The Administrator and DON stated that room visitation was prohibited because of concerns that visitors could bring drugs into the facility, but they were unable to provide documentation showing current drug activity in the facility. They also stated that exceptions were made only for residents who were bedbound or had health-related concerns, while other residents were not permitted room visits.
Failure to Honor Resident Visitation Rights
Penalty
Summary
The facility failed to ensure visitation rights were honored for Resident #33, who had diagnoses including schizoaffective disorder, cerebral infarction, and Parkinson's disease. The resident's quarterly MDS showed a BIMS score of 12 and that she required supervision assistance with toileting, transfers, and personal hygiene. Progress notes documented that she enjoyed visits from her family and going on outside family visits, and the resident stated during interview that she wanted her sister to visit. The Administrator stated that the resident's sister was banned from visiting after an incident involving the family member and staff, despite no formal or legal documents preventing visitation, and confirmed that the resident still desired visits with her sister and no accommodations had been made. The facility policy stated residents are permitted to have visitors of their choice at the time of their choosing and that the facility provides access for individuals visiting with the resident's consent.
Visitation Restriction Imposed Without Considering Resident Preference
Penalty
Summary
The facility failed to ensure one resident had her right to receive visitors of her choosing and to have her visitation preferences considered before a restriction was imposed. The resident was admitted with hemiplegia, cerebral infarction, and diabetes mellitus, and her MDS showed dependence with toileting, showering, lower body dressing, and putting on and taking off shoes. Her H&P stated she did not have the capacity to understand and make decisions. During an interview, the resident stated her son was not abusing her, denied that he intended to harm her, became tearful, and said she wanted him to continue visiting her. She also stated the facility forced visits with her son to occur only in the family room or other common areas instead of in her room as she preferred. The resident's son stated he visited his mother frequently and that after he pinched her left thigh, the facility told him he could not visit her in her room and limited visits to the family room or front area. An LVN stated she witnessed the son pinch the resident's left thigh, saw the resident awaken and swing her arms, and reported the incident to the RNS, CCO, and Administrator. The CCO stated the resident told her she was not afraid of her son and wanted him to continue visiting, but the facility still implemented a visitation restriction while the allegation was under investigation. The CCO also stated the facility did not explain grievance or appeal rights related to the restriction and did not fully consider the resident's visitation preferences before imposing it. The facility's visitation policy stated residents have the right to receive visitors of their choosing subject to reasonable clinical and safety restrictions.
Resident Visitor Preference Not Honored
Penalty
Summary
The facility failed to ensure a resident had the right to visitors according to her preference. Resident #17 was admitted with diagnoses including cerebral infarction due to embolism of an unspecified cerebral artery, COPD, morbid obesity due to excess calories, type 2 diabetes mellitus without complications, schizoaffective disorder, and polyneuropathy. Her quarterly MDS assessment identified her as cognitively intact, and she was her own responsible party. Interview and record review showed that after an incident involving Resident #17 and her friend during a facility bible study activity, multiple residents complained about the friend's behavior. The Activities Manager and Executive Director spoke with the resident's son, who did not know who the friend was, and he approved the facility contacting the friend to tell her she was no longer to visit Resident #17, while requesting staff not tell Resident #17 about the conversation. The Activities Manager confirmed she contacted the friend and informed her of the facility decision. Resident #17 later stated she wanted her friend to still be able to visit and that they could simply avoid bible study. The DON verified Resident #17 did not have a POA and that her son was her advocate and emergency contact. The facility policy stated it would provide reasonable access to a resident by any entity or individual, subject to the resident's right to deny or withdraw consent at any time.
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