Failure to Inform Resident of Medications Before Administration
Summary
The facility did not ensure that one resident was fully informed of resident rights, medication information, and options before medications were administered. During a medication administration observation, RN N entered the resident’s room and placed medications on the table. The resident asked for applesauce, stated that chocolate pudding was not wanted, and said the resident did not want to take medications because the resident did not know what medications were being taken. The resident reported that medications had been changed so much that the resident no longer knew what was being taken and stated that something was causing dizziness, which had already been reported to staff. RN N told the resident that a list of medications could be made but that the nurse could not leave until the medications were taken. The resident then took medications one at a time, dropped two pills on the floor, and asked what one of the pills was. RN N said the medication was not entirely known but thought it was losartan, even though the surveyor later clarified that losartan was not the medication being administered and that the order for losartan was at bedtime, not in the morning. RN N then stated the pill must have been torsemide. The resident also began having a nosebleed during the medication pass. RN N later acknowledged that the resident should have been educated before taking the medications, and the DON stated that RN N should have printed the MAR and educated the resident before administering medications.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Outdated Resident Rights Poster: The facility failed to ensure the current RBOR poster was displayed for residents, visitors, and staff to review. Surveyors observed the poster in a locked glass case near the entrance, and it was dated 1/16. The DOSS confirmed it was outdated and said a new one needed to be ordered; no facility policy was provided.
The facility failed to ensure the current RBOR was provided to residents and posted for residents, visitors, and staff to review. The RBOR displayed at the entrances to the first, second, and third floor units was dated 4/14/09. The administrator stated they were not aware of changes to the RBOR, and the facility had not yet ordered new postings for the units.
Failure to inform residents of their rights: Record review showed resident rights were not discussed in multiple resident council meetings, and some meeting minutes were missing. In confidential interviews, 10 residents said staff had not reviewed their rights with them, and 7 were unsure of their rights. The AD said she did not know she was supposed to review and explain resident rights and was unaware of the Ombudsman, while the SW and ADM described differing expectations for how resident rights information was being shared.
Resident rights were not reviewed verbally or in writing during resident council meetings, and the posted rights notice was outdated. Several residents stated the rights had not been reviewed, and the admin confirmed the meetings did not include this review and the poster was not current.
Failure to provide a resident with oral and written notice of rights, rules, services, and charges at admission. A resident with major depression, HF, pulmonary HTN, and dementia had no signed acknowledgment of resident rights in the record. The RP said she was not informed of the resident’s rights or service details and later discovered the resident had been taken off Lexapro without notification. The ADM confirmed there was no evidence the admission packet or resident rights information had been provided.
A facility failed to periodically inform 7 sampled residents of their rights after admission. During a resident council meeting, the residents stated staff did not review resident rights and that rights were not reviewed at council meetings, and meeting minutes from several months showed no documentation that rights were reviewed. The Administrator stated they did not know whether resident rights were routinely reviewed with residents.
Outdated Resident Rights Poster
Penalty
Summary
The facility failed to ensure the most up to date Nursing Home Resident [NAME] of Rights poster was displayed for residents, visitors, and staff to review. On 7/8/26 at 8:47 a.m., surveyors observed the RBOR poster in a locked glass case in a small common area near the entrance, and it was dated 1/16. On 7/8/26 at 12:02 p.m., the Director of Social Services confirmed the poster was outdated and that a new one needed to be ordered. A facility policy was requested but not provided.
Outdated Resident Rights Notices Posted
Penalty
Summary
The facility failed to ensure the most up to date Nursing Home Resident Rights (RBOR) was provided to each resident and displayed for residents, visitors, and staff to review. On observation, the RBOR posted next to the double doors entering the first floor unit, second floor unit, and third floor unit was dated 4/14/09. During interview, the administrator stated at 8:26 a.m. that they were not aware there were changes to the RBOR, and later stated at 9:21 a.m. that they had started the process of providing updates to residents and resident representatives, but new postings for the units had not yet been ordered. The facility Resident Rights policy dated 10/24 indicated copies of resident rights were posted throughout the facility, but it did not address when the facility would provide notification of changes in State or Federal laws related to resident rights or facility rules during the residents' stay.
Failure to Inform Residents of Their Rights
Penalty
Summary
The facility failed to ensure residents were informed orally of their rights and provided ongoing communication about those rights during their stay. Record review showed resident council minutes did not document resident rights being reviewed or discussed at meetings dated 05/22/2025, 07/16/2025, 08/19/2025, 09/16/2025, 12/08/2025, 01/08/2026, 02/12/2026, 03/11/2026, or 04/08/2026, and the October and November 2025 minutes were not included in the records. A bulletin board observation on 05/12/2026 at 7:33 AM showed the resident rights posting on the wall. During confidential interviews, 10 residents stated staff had not discussed or reviewed their rights with them, and 7 of those residents said they were unsure which rights they had as residents of the facility. The AD stated on 05/14/2026 at 11:20 AM that she was not aware she should have been reviewing and explaining residents' rights until that morning and was unaware of the Ombudsman position or the facility Ombudsman. The SW stated she reviewed resident rights with residents and family members when grievances could not be resolved and assumed the AD reviewed resident rights in Resident Council meetings. The ADM stated he trained all staff on resident rights and expected the AD to review resident rights with residents and provide ongoing information on the Ombudsman.
Resident Rights Not Reviewed or Posted Current
Penalty
Summary
The facility failed to ensure the resident bill of rights were provided verbally and in writing for all residents. During review of Resident Council Minutes Forms for 2/24/26, 3/26/26, and 4/16/26, the minutes did not document that the resident rights were reviewed. When seven residents attended a resident council meeting held by the surveyor, the residents stated the rights had not been reviewed. One resident said the rights were given at admission and posted in the facility, while another resident said they had been admitted years ago and were not coherent at that time. At 11:45 a.m., the poster near the nurses' station was reviewed and was dated 9/19, not the current 12/25 resident rights poster. During interview, the administrator stated the life enrichment supervisor was responsible for the resident council meetings and verified that the resident rights were not reviewed during those meetings and that the poster was not current. The facility policy for Resident and Family Council stated the facility would provide meeting space, inform residents of meeting opportunities, and respond to council concerns, but it did not include review of resident rights in the agenda.
Failure to Provide Resident Rights Notice at Admission
Penalty
Summary
The facility failed to inform a resident, both orally and in writing in a language the resident understands, of her rights and all rules and regulations governing resident conduct and responsibilities during her stay. Review of the resident’s record showed no signed acknowledgment that she was informed of her rights and responsibilities prior to or at admission. The resident was admitted with diagnoses including major depression, heart failure, pulmonary hypertension, and dementia, and was observed lying in bed, alert, and oriented to name and place. She stated she did not know she was not receiving her major depression medication until her daughter informed her, and she reported no interest in activities because she was depressed. The resident’s responsible party stated the resident’s behavior was not normal, describing refusal of meals, waking at night, and loss of interest in everything. She said she discovered the resident was not taking Lexapro after requesting the medication list and stated the facility did not notify her before discontinuing the medication. She also stated she did not receive notice of rights and services during admission in oral or written form and had not signed admission documents. The administrator stated there was no evidence the resident was provided written information regarding resident rights on admission or after, that the facility did not have an admission packet for the resident, and that the packet could not be found.
Failure to Review Resident Rights
Penalty
Summary
The facility failed to periodically inform residents of their rights after admission for 7 of 7 sampled residents (Residents 7, 20, 35, 40, 49, 67, and 75) reviewed for resident rights. During a resident council meeting on 04/28/2026 at 2:07 PM, all seven residents stated that staff did not talk about or review resident rights in the facility, and they said resident rights were not reviewed at resident council meetings. Review of resident council meeting minutes from November 2025 through April 2026 showed no documentation or confirmation that resident rights were reviewed. In an interview on 04/30/2026 at 3:17 PM, the Administrator stated they did not know whether resident rights were routinely reviewed with residents in resident council or otherwise.
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