Failure to Provide Admission Agreements
Summary
The facility failed to provide a written notice of rights and services prior to or upon admission for three sampled residents. For Resident 1, the admission agreement was provided more than nine months after admission. Resident 1 had multiple diagnoses, including dementia and major depressive disorder, and lacked the capacity to understand healthcare decisions. The Assistant Director of Nursing confirmed that the admission agreement was not provided until much later. For Residents 2 and 3, no admission agreements were provided during their stay. Resident 2, who was receiving palliative care for pancreatic cancer and had Alzheimer's disease, was oriented to the facility but did not receive an admission agreement before passing away shortly after admission. Resident 3, who was self-responsible, was admitted and discharged without receiving an admission agreement. The Medical Records Director confirmed the absence of signed agreements for these residents. The facility's policy required that admission agreements be signed at the time of admission, but this was not adhered to, potentially leaving residents unaware of their rights.
Penalty
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A resident with severe cognitive impairment and multiple chronic conditions required assistance with all ADLs. The resident’s daughter requested facility policies related to medication administration and bed alarms to support her participation in the care planning process, but the facility did not provide them. Facility leadership acknowledged that the request was not fulfilled, citing ongoing revisions to the policies and concerns about distributing outdated versions, and there was no existing policy governing how requested facility policies should be provided to residents or their representatives.
The facility did not review Resident Rights during Resident Council meetings for several months, as confirmed by resident and staff interviews and review of meeting minutes. Multiple residents who attended these meetings were unaware of where to find information about their rights, and the omission was attributed to a change in agenda forms by the Activities Director.
The facility did not provide ongoing communication about resident rights during Resident Council meetings, as confirmed by a review of meeting minutes and interviews with a resident and the Activity Director. This omission had the potential to affect all residents in the facility.
Failure to Provide Requested Facility Policies to Resident Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident’s representative with requested facility policies necessary to support participation in the person-centered care planning process. The resident involved was admitted on 08/12/24 and had multiple diagnoses, including chronic kidney disease stage IIIA, hypertension, hyperlipidemia, polyneuropathy, osteoarthritis, dementia, hypothyroidism, chronic pain, generalized muscle weakness, cardiac murmur, amnesia, photokeratitis, and dermatitis. The most recent quarterly MDS assessment showed a BIMS score of three, indicating severe cognitive impairment, and documented that the resident required at least limited assistance with all activities of daily living, including eating, hygiene, toileting, dressing, transferring, and ambulation. Between 03/30/26 and 04/02/26, interviews with family and staff revealed that the resident’s daughter requested facility policies related to medication administration and bed alarms, but the facility did not provide them. In an interview on 04/01/26 with the Administrator, the Regional Director of Operations, and the Regional Director of Clinical Services, facility leadership confirmed that the daughter had requested these policies and that they were not provided. During the exit conference on 04/02/26, the Regional Director of Operations again acknowledged that the request was not fulfilled and explained that the facility did not provide the policies because they were undergoing revisions and the facility could not ensure distribution of updated versions. Review of facility policies further showed there was no policy addressing the provision of facility policies to residents or their representatives upon request.
Failure to Review Resident Rights During Resident Council Meetings
Penalty
Summary
The facility failed to ensure that residents were informed of their Resident Rights, as required by policy. Review of Resident Council meeting minutes over an 11-month period showed that Resident Rights were not discussed during these meetings. Interviews with several residents confirmed that they were not aware of where to find information about their rights and that these rights had not been reviewed during Resident Council sessions. The Activities Director acknowledged that Resident Rights were omitted from the meetings due to a change in the agenda forms. Facility policy indicated that Resident Rights should be reviewed during Resident Council meetings, but this was not done, affecting multiple residents who attended these meetings.
Failure to Communicate Resident Rights During Council Meetings
Penalty
Summary
The facility failed to provide ongoing communication to residents regarding their rights, as evidenced by a review of Resident Council meeting minutes over a period of several months, which showed no documentation of resident rights being discussed. An interview with a resident confirmed that staff did not review resident rights during Resident Council meetings. Additionally, the Activity Director, who had been conducting the meetings since September 2024, acknowledged that she was not discussing resident rights with residents and only became aware of the requirement to do so in March 2025. This lack of communication regarding resident rights had the potential to affect all residents in the facility, which had a census of 44 at the time of the survey.
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