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 Surveyors observed an outdated RBOR posted on the first floor, while the admission packet and a wall-hanger copy contained a later revised version.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Outdated Resident Bill of Rights Posted: An outdated RBOR was observed posted in the facility, and the SSD confirmed the information was outdated.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 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Outdated Resident Rights Poster: The facility failed to ensure the current RBOR poster was displayed for residents, visitors, and staff to review.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 The DOSS confirmed it was outdated and said a new one needed to be ordered; no facility policy was provided.
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.
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rights were not reviewed verbally or in writing during resident council meetings, and the posted rights notice was outdated.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 Review Resident Rights in Council Meetings: Four cognitively intact residents who regularly attended resident council meetings did not recall resident rights ever being discussed, and meeting minutes did not document any review of rights. A resident rights poster was posted in a hallway, but the residents said they did not know where it was located. The LED could not find documentation that rights were reviewed, and the Admin said the process was not yet standardized.
The facility failed to ensure the current RBOR was posted for residents, visitors, and staff and provided to all residents. Surveyors found outdated 2016 RBOR postings and paper copies in common areas, while the admission packet contained a newer RBOR. SS staff said updated pamphlets were ordered for new admissions, but residents admitted earlier had not been informed of the update, and the administrator was unaware the RBOR had changed.
Resident rights notices were not kept current and were not being reviewed with residents during council meetings. A resident rights poster by the elevator was dated December 2015 even though the federal and state rights form had been updated, and the SW stated the admission packet still contained a December 2017 version. The resident council reported staff had not reviewed resident rights at meetings for about a year.
Outdated Resident Rights posters were observed in the facility, including one near the entrance and another by the elevator, both displaying older dates. The administrator stated she was unaware of the newly released poster effective 1/1/26 that was meant to replace prior versions. The facility policy required residents to be informed of their rights and for the Resident Rights to be posted in a conspicuous location.
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