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.
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