Failure to Ensure Residents and Representatives Understood Binding Arbitration Agreements
Summary
Facility staff failed to ensure that residents and/or their representatives understood the binding arbitration agreements included in the admission packet. The facility’s standard arbitration form stated that any disputes regarding services or health care provided by the facility would be resolved through binding arbitration, that signing the agreement waived statutory and constitutional rights to have claims decided in court before a judge and jury, and that signing was not a precondition for admission. The agreement also stated that the resident should seek legal counsel and that the agreement could be rescinded in writing within 30 days by certified mail. However, interviews with residents and representatives who had signed these agreements showed no evidence that staff clearly explained these provisions or confirmed that signers understood what they were agreeing to. One resident with multiple sclerosis, muscle spasms, contractures, anemia, and weakness was cognitively intact with a BIMS score of 14 and had electronically signed the arbitration agreement as his own representative. He reported understanding the concept of arbitration generally but did not remember signing the facility’s arbitration agreement and stated he was not clear on what he was signing at the time. He did not recall the admissions staff clearly explaining that he should seek legal counsel before signing or that he would be giving up certain legal rights, and he stated that he would not have signed had he understood this. Another resident with dysphagia, hemiplegia following cerebral infarction, a gastrostomy, type 2 diabetes, cognitive communication issues, generalized muscle weakness, and gout had an initial BIMS score of 0, indicating severely impaired cognition, and a later BIMS score of 15, indicating intact cognition. The arbitration agreement for this resident was signed by the resident and an emergency contact as representative. During a telephone interview, the emergency contact stated they did not remember signing anything that would prevent the resident or family from taking the facility to court, and that the arbitration process and agreement were not made clear before signing. A third resident with rib fracture, protein-calorie malnutrition, atrial fibrillation, systolic congestive heart failure, generalized muscle weakness, and cognitive communication deficit was documented as her own responsible party and had a BIMS score of 15, indicating intact cognition. The arbitration agreement in her record was electronically signed by an emergency contact as her representative. The resident stated she did not remember signing any legal papers like that, noted there were many papers to sign at admission, and reported that a family member present at admission would not have allowed her to sign such a document. A fourth resident with hemiplegia, clavicle fracture, hematuria, generalized muscle weakness, adjustment disorder, and cognitive communication deficit had a BIMS score of 14 and a power of attorney as representative. The arbitration agreement was electronically signed by the representative, who later stated she did not understand what she was signing, was unsure how arbitration works, and was more focused on the resident’s health at the time. She did not recall being advised to seek legal counsel or being clearly informed that signing meant giving up the right to pursue legal action in court. The Director of Admissions reported that arbitration agreements are included in the admission packet and that she waits for a BIMS score before reviewing them with residents or representatives. She stated that for residents with BIMS scores of 12 or higher, she meets with the resident and/or representative to review the admission packet and arbitration agreement, and for residents with lower BIMS scores she meets with the representative if they wish to sign. She described asking whether they had heard of binding arbitration and explaining that by signing they agree to use the facility’s arbitrator rather than their own legal counsel for unresolved grievances, disputes, or legal matters, and that signing is voluntary and not required for admission. She also stated she tells them they have 30 days to change their minds, but acknowledged that the process she described for rescinding—contacting her by phone or in person so she can notify the regional office—is not outlined in the document itself, which specifies rescission by written notice via certified mail. When asked how she determines understanding, she stated that she simply asks if they understand, and surveyor interviews found no evidence that staff explanations ensured residents or representatives truly understood the binding arbitration agreements they signed.
Penalty
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Below are regulatory guidelines relevant to this citation:
A facility arbitration agreement stated that a resident was not required to sign to be admitted or continue care, but it required rescission within 30 days by signed written letter only. The SSD said she explained the agreement before admission and confirmed that verbal withdrawal was not allowed, meaning residents or representatives could only retract consent in writing.
A resident with Parkinson's disease, dementia, anxiety, and DM had moderately impaired cognition and could not make medical decisions. The facility's admission coordinator said the resident's RP signed a binding arbitration agreement, but the RP stated he never signed it and had never been told about it. Staff also acknowledged the agreement should be explained before signing, and the facility policy required it to be explained in language the resident or RP could understand.
Binding arbitration agreements were not clearly communicated in a form and manner understood by a resident before signing. A resident with intact cognition, dementia, moderate vision impairment, and a need for help reading written materials signed an undated arbitration agreement, but later stated he would not have signed it and could not read or write. Staff described limited training and inconsistent explanations of the agreement, and the facility document lacked evidence that the resident or representative understood the terms or that the agreement was explained in a language they understood.
Failure to Properly Explain Arbitration Agreements: The facility did not inform 4 of 4 reviewed residents or their representatives that signing an arbitration agreement was not required for admission or continued care, and did not explain the agreement in a way they could understand. Two residents had moderate cognitive impairment, one resident on the dementia unit later said she did not know what an arbitration agreement was, and another resident stated he did not understand the term and spoke a primary language other than English. A staff member said she briefly described the form as a litigation question and did not provide any other details.
Arbitration Agreement Signed by Resident Without Capacity: A resident with legal blindness, cognitive impairment, and no capacity to make decisions signed an arbitration agreement even though a Family Member was the responsible party. The AC stated the form should have been reviewed and signed by the responsible party, and facility policy required the arbitration offer to be explained in a language and manner the resident or legal representative could understand.
A facility failed to follow its BAA policy for three residents whose primary language was Spanish. Admission staff presented English-language arbitration forms, and there was no documentation that the agreements were explained in Spanish or that the residents acknowledged understanding them. Two residents with intact cognition and one resident with moderately impaired cognition stated they signed the forms without understanding what they were signing.
Arbitration Agreement Did Not Allow Verbal Rescission
Penalty
Summary
The facility failed to ensure arbitration agreements were implemented in a manner that protected resident rights. An agreement titled ARBITRATION AGREEMENT AND WAIVER OF JURY TRIAL stated that residents were not required to sign the agreement to be admitted or continue receiving care, but it also required any rescission to be made by sending a signed written letter to the facility within the first 30 days after signing. During interview, the Social Service Director stated that her role was to explain the arbitration agreement to residents and families before admission, and that after signing, a resident or representative had 30 days to retract consent only by submitting a written request. She confirmed that the agreement did not allow verbal withdrawal from the agreement.
Arbitration Agreement Not Clearly Explained to Resident Representative
Penalty
Summary
The facility failed to ensure the terms and conditions of a binding arbitration agreement were clearly explained to the resident or the resident representative for one sampled resident. Resident 90 was initially admitted on 9/2/2024 and later readmitted with diagnoses including Parkinson's disease, unspecified dementia, anxiety disorder, and diabetes mellitus. The resident's MDS dated 6/12/2026 indicated moderately impaired cognitive skills, and a physician progress note dated 5/13/2026 stated the resident could make needs known but could not make medical decisions; the note identified FM1 as the responsible party. During interviews, FM1 stated he never signed an arbitration agreement for Resident 90 and had never been told about it, despite stating he was responsible for signing all forms and consents for the resident. The admission coordinator stated FM1 signed the arbitration agreement on 3/20/2026 and acknowledged she could not remember whether she had spoken directly with FM1 about the form. The coordinator stated the arbitration form should be explained to the resident or representative before signing, and the QA nurse stated the purpose and context of the agreement should be discussed so the resident or representative understands the terms and effect of signing. The facility policy stated the agreement would be explained in a manner and language the resident and representative understand, and that if the resident lacked decision-making capacity, the resident representative would decide whether to sign or decline.
Binding Arbitration Agreement Not Clearly Explained
Penalty
Summary
The facility failed to ensure a binding arbitration agreement was clearly communicated in a form and manner understood by a resident prior to signing. Resident R43’s admission MDS indicated intact cognition, diagnoses of non-Alzheimer’s dementia, moderate vision impairment, and a need for someone to help read written materials. Exhibit H, the undated Binding Arbitration Agreement, contained R43’s signature. During interview, R43 stated he would not have signed a binding arbitration agreement, said legal issues at the time of admission would have prevented him from signing, and stated he was not able to read or write and would therefore require assistance. During interviews, social services staff stated he completed the binding arbitration with R43 and explained it as a legal form that would speed up the process if residents brought the facility to court, while stating he would not have told residents they were giving up any rights. He also stated he had limited training on binding arbitration and had been responsible for all such agreements until they were transferred to the admission coordinator on 5/1/26. The admission coordinator stated she presented binding arbitration upon admission and would stop and discuss it with family if a resident did not understand. The Administrator stated all binding arbitration agreements were grandfathered in. A facility document titled Explanation of Arbitration Agreement Language to Family and Resident/Patient stated arbitration does not occur in a court, but it lacked indication that the agreement was explained in a form and manner the resident or representative understood, including in a language they understood, and lacked resident or representative acknowledgement of understanding.
Failure to Properly Explain Arbitration Agreements
Penalty
Summary
The facility failed to inform residents or their representatives of the right not to sign a binding arbitration agreement as a condition of admission or continued care, and failed to explain the agreement in a manner they could understand, including in a language they understood, for 4 of 4 residents reviewed. R25 was admitted to the dementia unit, had a Brief Interview for Mental Status showing a memory problem and moderate impairment in decision-making, and her arbitration contract was signed by her; however, when interviewed later she stated she did not know what an arbitration agreement was and said she never agreed to arbitration. R83 was also moderately cognitively impaired, had an arbitration contract signed by himself, and later stated he did not know what arbitration meant and that his primary language is Tajlogy (Philippines).
Arbitration Agreement Signed by Resident Without Capacity
Penalty
Summary
The facility failed to ensure the Arbitration Agreement form was not signed by Resident 1, who had a responsible party, was not self-responsible, had cognitive impairment, did not have the capacity to understand and make decisions, and was legally blind. Resident 1’s admission record showed diagnoses including legal blindness, chronic kidney disease, benign prostatic hyperplasia, and hypertension, and identified a Family Member as the responsible party. The History and Physical dated 2/27/2026 stated Resident 1 did not have the capacity to understand and make decisions, and the MDS dated 3/18/2026 indicated moderately impaired cognitive skills and dependence on staff with ADLs. The Arbitration Agreement form dated 7/9/2024 showed Resident 1 signed the form. During interview, the admission Coordinator stated she was responsible for explaining the Arbitration Agreement to residents and/or responsible parties, and that if a resident was not self-responsible, the form should have been reviewed and signed by the responsible party. She stated Resident 1’s responsible party should have signed the form, and that the risk of having Resident 1 sign it could result in the Family Member taking legal action against the facility. The facility policy stated the arbitration offered to residents or their responsible parties should be explained in a language and manner they understand and provide opportunities for questions, and that the resident or legal representative may accept or decline the agreement.
Binding Arbitration Agreements Not Explained in Residents’ Primary Language
Penalty
Summary
The facility failed to follow its Binding Arbitration Agreement policy for three sampled residents when admission staff did not provide documentation and explanation of the agreement in the residents’ primary language. Resident 32, Resident 41, and Resident 80 each had a BAA written in English, and the admission coordinator stated there was no documentation showing the agreement was explained in Spanish for any of them. Each resident stated Spanish was their primary language, and each reported signing the English form without understanding it or without recall of the explanation. Resident 32’s admission record identified Spanish as the primary language, and the MDS showed a BIMS score of 8, indicating moderately impaired cognition. Resident 41’s admission record also identified Spanish as the primary language, and the MDS showed a BIMS score of 14, indicating intact cognition. Resident 80’s admission record identified Spanish as the primary language, and the MDS showed a BIMS score of 14. The facility policy stated the arbitration agreement must be explained in a form and manner the resident understands, including in a language the resident understands, and that the resident or representative must acknowledge understanding.
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