Failure to Provide Admission Packet and Communicate Resident Rights and Advance Directives
Summary
The deficiency involves the facility’s failure to inform a resident, both orally and in writing, of her rights, rules, responsibilities, and facility policies at the time of admission. The resident was an elderly female admitted with diagnoses including UTI, history of colon cancer and large intestine, hypertension, irregular heartbeat, presence of a pacemaker, and mild cognitive impairment, with a BIMS score of 12/15 indicating moderately impaired cognition. Her face sheet listed a family member as Emergency Contact and POA for healthcare, and her advance directives section was blank. Progress notes documented that she arrived in the evening by EMS, was A&O x2, oriented to the room and equipment, and did not voice concerns at that time. However, the electronic medical record contained no admission packet or admission agreement for her. Interviews with facility staff revealed inconsistent and incomplete practices regarding the admissions packet, which contained resident rights, rules governing resident conduct, responsibilities, charges, and advance directive information. The Administrator stated that resident rights were communicated through the admissions process and packet, and that the Admissions Coordinator and Marketing were responsible for completion of the packet, which should be provided before or at admission and completed within 72 hours. The DON similarly stated that the packet was sent prior to arrival and completed shortly after admission. In contrast, the Admissions Coordinator initially described her role as getting the room ready and ensuring a good stay, and stated she was not responsible for reviewing documentation. She later stated she was responsible for the admission packet, usually completed after admission and provided via email or in person within 48 hours, but that she did not review the packet contents with residents or their representatives. For this resident, the Admissions Coordinator acknowledged that no admission packet was created or provided, and that the resident’s POA, who was present at admission, never received the packet or any communication of resident rights or other packet contents. She stated she intentionally did not send the packet because she had not yet confirmed the POA status, even though the executed POA was included in documentation received before and after admission. The family member/POA reported that the resident was very confused and distressed on admission, repeatedly stating that people were trying to kill or harm her, and that the family member never received an admission packet or any documentation of rights or other information. The Administrator stated that failure to deliver or communicate the contents of the admissions packet could leave residents unaware of their rights and the facility unaware of residents’ wishes. The record also showed that the resident’s advance directives were not documented in the facility record, and on a later date she received CPR when unresponsive despite her wishes being DNR, with the hospital having handled the DNR paperwork.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Resident Bill of Rights Not Updated or Reviewed: The facility failed to ensure the most current RBOR was provided to residents and displayed for residents, visitors, and staff. A resident said the RBOR was posted but did not recall anyone reviewing it at admission. Surveyors observed an outdated RBOR posted on the first floor, while the admission packet and a wall-hanger copy contained a later revised version. The DON and SSD stated they were not aware the RBOR had been updated, and the SSD did not personally review it with residents at admission.
Outdated Resident Bill of Rights Posted: An outdated RBOR was observed posted in the facility, and the SSD confirmed the information was outdated. The SSD stated it was their responsibility to keep the posting updated, but it had not been completed. A policy regarding posting the RBOR was requested and none was provided.
A resident was not shown to have been informed, orally and in writing, of resident rights upon admission. The admission packet included a Resident Rights and Facility Responsibilities document and an acknowledgment form, but the medical record had no completed acknowledgment, no documentation that the rights were explained orally, and no note that the resident understood or acknowledged them. The Administrator stated the admission paperwork, including the Resident Rights and Resident Handbook acknowledgments, could not be located.
Admission Documents Not Communicated in Resident’s Language: A resident whose primary language is Spanish signed multiple English-language admission, financial, consent, and resident-right documents without documented translation, interpreter support, or an independent witness. The admissions director stated she does not speak Spanish, used a tablet for translation, and confirmed there was no documentation showing the paperwork was explained in Spanish or otherwise communicated in a way the resident could understand.
A resident was not given the Resident Bill of Rights orally or in writing upon admission, and the chart lacked documentation that it was provided. The DON and administrator gave differing accounts of who was responsible for reviewing the rights and grievance process, and the resident stated staff did not verbally educate her or provide a written copy. Facility policy referenced resident rights and grievance information, but one policy did not direct staff to provide the Bill of Rights upon admission.
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.
Resident Bill of Rights Not Updated or Reviewed
Penalty
Summary
The facility failed to ensure the most up to date Nursing Home Resident Bill of Rights (RBOR) was provided to each resident and displayed for residents, visitors, and staff to review. During interview, a resident stated the RBOR was posted on the first floor but did not recall anyone sitting down and going over the bill of rights. Observation showed the RBOR displayed across from the kitchen door on the first floor was dated 7/1/07. Review of the admission packet showed an RBOR revised 11/28/16 and modified 2/1/17, and another RBOR in a clear plastic wall hanger was also modified 2/1/17. The DON stated the social service director worked with marketing and ordered items needed for the admission packets, and that they were not aware the RBOR had been updated. The SSD stated they did not personally go over the RBOR at admission and were not aware who was responsible for updating the posters or whether residents had been updated regarding the revised RBOR. A policy regarding RBOR was requested but not provided.
Outdated Resident Bill of Rights Posted
Penalty
Summary
The facility failed to ensure residents were promptly informed of changes to the Nursing Home Resident Bill of Rights and failed to ensure the current RBOR was available and displayed for residents, staff, and visitors to review. During observation on 7/30/26 at 2:25 p.m., an outdated RBOR was posted in the facility. The social services director confirmed at that time that the posted RBOR information was outdated and stated it was their responsibility to hang and keep the information updated, but it had not been completed. A policy regarding posting the RBOR was requested and none was provided.
Failure to Provide and Document Resident Rights Acknowledgment
Penalty
Summary
The facility failed to ensure that Resident #12 was informed, both orally and in writing, of the resident's rights upon admission. A review of the admission packet showed a document titled Resident Rights and Facility Responsibilities stating that each resident has the right to be informed, orally and in writing, in a language the resident understands, of rights and the rules and regulations governing conduct and responsibilities during the stay. The packet also included a Resident Rights acknowledgment form stating that the resident had read or had the rights read to them and understood them. Resident #12's medical record did not contain a completed acknowledgment of resident rights. There was no documentation showing that Resident #12 signed to acknowledge receipt of the resident rights, no documentation that the rights were provided orally, and no note indicating the resident understood or acknowledged them. During interview, the Administrator stated that leadership was unable to locate Resident #12's admission paperwork, including the acknowledgment of receiving the Resident Rights and the Resident Handbook.
Admission Documents Not Communicated in Resident’s Language
Penalty
Summary
The facility failed to inform one resident, whose primary language is Spanish and who does not speak, read, or understand English, of his rights and the rules and regulations governing resident conduct and responsibilities in a language he could understand. Upon admission, the resident signed numerous admission, financial, consent, and resident-right documents written in English, including the admission summary, financial policies, advance directives information, grievance procedure, non-discrimination notice, abuse and zero tolerance information, visiting policy, resident rights, and a legal arbitration agreement. The majority of these documents were also signed by the admissions director, Employee E8. Review of the resident’s record showed no documentation that the admission documents were translated into Spanish, interpreted by a qualified medical interpreter, reviewed through a language assistance service, or otherwise communicated in a manner the resident could understand before signatures were obtained. There was no documentation identifying an interpreter, translator, bilingual staff member, or witness to confirm the contents were accurately explained. The resident’s care plan identified communication needs, noting that staff should use nonverbal communication techniques, gestures, verbal and visual cues, and a Spanish-English communication board. During interview, the admissions director stated she does not speak Spanish, used a tablet for translation, and confirmed there was no notation showing a translation method was used, no Spanish paperwork, and no independent witness present during the signing process.
Failure to Provide Resident Bill of Rights on Admission
Penalty
Summary
The facility failed to provide 1 of 3 residents, R5, with the Resident Bill of Rights orally or in writing upon admission. R5's chart did not contain documentation that she received a copy of the Resident Bill of Rights. During interviews, the DON stated the administrator was responsible for reviewing the Bill of Rights and explaining the grievance process to new residents upon admission, while the administrator stated the admitting nurse was responsible for informing new residents of the rights and the DON was responsible for verifying the admission process was complete. The administrator also stated the admission process was not in written form, acknowledged R5's chart lacked evidence that she was provided the Resident Bill of Rights, and noted that a full listing of the rights was posted on a facility wall. R5 stated she was not given a written copy when admitted and was not verbally educated or reviewed on the rights. The facility's Resident Rights and Responsibilities policy listed resident rights and grievance information but did not direct staff to provide the Resident Bill of Rights prior to or upon admission, while the Abuse Prevention policy stated residents and families are informed on admission how to report concerns, incidents, and grievances and that a copy of the Resident Bill of Rights is provided and covered upon every admission.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release October 8, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.