Failure to Provide Private Telephone Access for Residents
Summary
The facility failed to ensure residents had reasonable access to and privacy in their use of telephones, affecting three sampled residents. Resident 1, admitted with diagnoses including diabetes mellitus and chronic kidney disease, had intact cognition and required substantial assistance with transfers and walking. Resident 3, with diabetes mellitus and atrial fibrillation, had mildly impaired cognition and required supervision or moderate assistance with mobility. Resident 2, with heart failure and chronic kidney disease, had moderately impaired cognition and was dependent on staff for transfers. These residents relied on staff and facility resources to access telephones for personal communication. Staff interviews and observations showed that, following a change in facility ownership, the previous owner confiscated all work phones and residents’ phones for private use, and the facility no longer had a dedicated resident cell phone. RN 1 reported that residents who were able to ambulate used the phone at the nursing station, while bedbound residents used the nursing staff’s work cell phone, which contained sensitive information about many residents. Because of this, staff remained with residents during calls to prevent access to confidential information on the device, acknowledging that this could be a violation of privacy since staff could hear the conversations, even though they tried not to listen. Resident interviews and direct observations confirmed the lack of private telephone access. Resident 2, who was bedbound, stated she previously spoke with her daughter weekly but had been unable to do so for a couple of months because the facility no longer allowed her to use the phone and she could not get out of bed to reach the nursing station phone. Resident 3 stated that when he needed to use the phone, he did so at the nursing station and had conversations in front of staff. Resident 1 was observed using the phone at the nursing station while RN 1 sat nearby. The Social Services Director and the Administrator both confirmed that, as an interim measure, residents were using the RN supervisor’s work cell phone under staff monitoring, which prevented residents from having private telephone conversations. Facility policies on confidentiality and resident rights stated that residents would have their written and telephone communications protected and would have access to a telephone with privacy, which was not being met in these instances. These failures resulted in Resident's 1, 2, and 3 being unable to make personal phone calls without staff's presence and monitoring, violating their rights to private communication. These deficient practices had the potential to cause psychosocial harm, including fear of being overheard when discussing personal information, and feelings of distress and isolation due to lack of communication with family.
Penalty
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Below are regulatory guidelines relevant to this citation:
A cognitively intact resident with psychiatric and respiratory diagnoses was on a speaker-phone call with family in a common area where multiple people could hear the conversation, and the resident stated she could not move to a private location. An unknown staff member then intervened, told the family they would need to come in and speak with the DON if they wished to talk to the resident, and abruptly ended the call. The Administrator and Social Services Designee confirmed that the resident was not offered or provided a private place for the call and that staff terminated the conversation, contrary to the facility’s written policy guaranteeing residents private access to telephone communication.
Delayed Weekend Mail Distribution: Residents did not receive mail delivered on Saturdays. Resident council members stated they do not get any mail on Saturdays, and the DLE and BOM confirmed that activity staff distribute mail and that weekend mail is held until Monday before being given to residents.
A resident with dementia and anxiety, who required a private room for psychosocial needs, was unable to have private phone conversations due to the lack of a functional phone in their room and the use of a non-private nurses' station phone. Staff confirmed that conversations could be overheard, and facility policy referenced the right to private communications, but no designated private area was available.
A resident with a history of mental health diagnoses and intact cognition was unable to access a private area for telephone use, as facility phones were located in open, public spaces where conversations could be overheard. Staff interviews confirmed the lack of private phone areas, and facility policies requiring privacy for resident communications were not followed.
A resident with severe cognitive impairment did not have access to a working bedside phone, requiring her to use the nurse's station for family calls. Staff were unaware of alternative private phone options, and the facility's policy for private phone access was not effectively communicated or implemented, resulting in a lack of privacy for the resident's phone communication.
Residents did not consistently receive their mail on weekends, as confirmed by both resident interviews and staff statements. The facility's policy requires that residents have access to their mail, but this was not ensured during weekends.
Failure to Provide Resident Privacy During Telephone Communication
Penalty
Summary
The facility failed to ensure a resident had privacy during a telephone call with family, as required by resident rights and the facility’s own policy. The resident, admitted in mid-February 2026, had diagnoses including schizophrenia, anxiety, adjustment disorder with mixed anxiety and depression, and emphysema, and was documented as cognitively intact on the admission MDS. An audio recording of a family-initiated call to the facility’s telephone showed that the resident accepted the call and identified herself, along with her son and daughter-in-law. During the call, the resident told her family she was on speaker phone with many people around listening. When her son asked if she could go somewhere private, the resident stated she could not. The audio recording further revealed that an unknown facility employee intervened in the call, told the family that if they wished to speak with the resident they would need to come to the facility and speak with the DON, and then abruptly ended the call. The Administrator confirmed that the recording involved the resident, her family, and an unknown staff member, and verified that privacy was neither offered nor provided and that a staff member abruptly terminated the call. The Social Services Designee reported being contacted by the night shift nurse about the family’s request to speak with the resident and stated she had advised that if the resident wanted to speak with her family, staff could not stop her. She also verified that the resident was not provided a private place for the call and that an unknown staff member abruptly ended the conversation. Review of the facility’s Resident-Patient Rights policy, revised February 2026, showed that residents were to have access to telephone communication with privacy, which was not afforded in this incident.
Delayed Weekend Mail Distribution
Penalty
Summary
The facility failed to ensure residents had reasonable access to and privacy in their use of communication methods when residents did not receive delivered mail on Saturdays. During interview, Resident Council Members #48, #59, #85, and #88 stated they do not receive any mail on Saturdays and that activity staff distribute mail at the facility. The Director of Life Enrichment stated activity staff distribute mail and that mail received on weekends is distributed to residents on Monday. The Business Office Manager stated mail is dropped off by post office staff in the mail room, but mail delivered on weekends is not given to residents until Monday, so residents do not receive Saturday mail until the following week.
Failure to Provide Private Space for Resident Phone Conversations
Penalty
Summary
The facility failed to provide a private space for phone conversations, resulting in a deficiency affecting one resident out of three reviewed for reasonable access to privacy. The resident in question had diagnoses including dementia without behaviors, anxiety, and a history of stroke, and was assessed as having normal cognitive function. The resident's care plan indicated a need for a private room due to psychosocial needs. Observations revealed that the resident did not have access to a working phone in his room, and staff interviews confirmed that residents typically used the phone at the nurses' station, which was not a private area and could be overheard by staff, visitors, or other residents. Further investigation showed that the cordless phone at the nurses' station was not operational, and when a corded phone was found in the resident's room, it was not plugged in or functional. Staff confirmed that the resident made calls from the nurses' station and that conversations could be overheard, as evidenced by a staff member overhearing a personal conversation about cigarettes. The facility's policy referenced the right to private and unrestricted communications, but the lack of a designated private area and non-functional phones resulted in the resident's inability to have private phone conversations.
Failure to Provide Private Telephone Access for Resident
Penalty
Summary
The facility failed to provide a resident with reasonable access to a telephone in a private setting, as required by both facility policy and resident rights. Observations revealed that the designated telephone stations were located in open areas without doors or walls, allowing conversations to be overheard by staff, residents, and visitors. One resident, who had a history of paranoid schizophrenia, psychosis, anxiety disorder, and personality disorder, and who was cognitively intact and independent with ADLs, was observed making phone calls in these open areas. The resident expressed concerns about the lack of privacy, stating a preference for one phone location over another due to less foot traffic, but still noted there was no privacy available. Interviews with staff, including CNAs, an LPN, the Infection Preventionist, the Interim DON, and the Administrator, confirmed that the facility's phones were not portable and were situated in open, non-private locations. Staff acknowledged the lack of designated private areas for resident phone calls, and the Infection Preventionist reported occasionally offering his office for private calls. Facility policies reviewed indicated that residents were guaranteed the right to private communication, and that telephones should be located in areas offering privacy, but these policies were not being followed in practice.
Failure to Ensure Resident Privacy and Access for Telephone Communication
Penalty
Summary
Facility staff failed to ensure that a resident had privacy and reasonable access to telephone communication. Observation revealed that the resident's bedside phone was not plugged in and the phone jack did not have service, a situation that had persisted for several months according to the roommate. The resident, who had severe cognitive impairment and was rarely understood, was unable to be interviewed, but it was confirmed that she had a guardian and a family member involved in her care. When the resident received calls from her family, she had to go to the nurse's station to communicate, as her room phone was nonfunctional and lacked a cord to connect to the outlet. Staff interviews showed inconsistent knowledge about the availability of alternative phones for private use, with some LPNs unaware of any facility-provided cell phone and unable to locate one. The Unit Manager and Administrator were not aware that the resident's phone was unusable or that not all room phones had service. Facility policy required reasonable access to phones in a private area, but staff were not aware of the designated private phone options in the Social Services or Business Office. This resulted in the resident not having private access to phone communication as required.
Failure to Deliver Resident Mail on Weekends
Penalty
Summary
The facility failed to ensure that residents received their mail on weekends, as required by their policy and resident rights. During interviews, several residents reported that mail was only delivered Monday through Friday, and not on weekends. The Activities Director confirmed that resident mail was not always delivered on weekends and stated that the weekend manager was responsible for this task. Review of the facility's Resident Rights policy indicated that residents have the right to send and receive mail, including privacy of such communication, but this was not consistently upheld for weekend mail delivery.
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