Based on observation, record review, and staff, Legal Guardian, and former facility Executive Director interviews, the facility failed to exercise the rights of the Resident's Representative when Resident #115 had unsupervised visits with her son despite restricted visitation instructions from the Legal Guardian. The Legal Guardian stated, on Friday 1/24/2025, she informed the Admission's Director and the Resident Concierge Resident #115 was not to have visits from her son without supervision. Resident #115 was cognitively impaired, was adjudicated incompetent, and had history of sexual interactions with her son that included sexual intercourse, open mouth kissing, and inappropriate touching as witnessed by the previous facility's Executive Director. …
F551
Resident Rights Deficiencies
Give the resident's representative the ability to exercise the resident's rights.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Every F551 citation surveyors wrote nationally that year.
Distinct nursing homes with at least one F551 finding.
The harm level
How severely F551 is cited
0.6% of citations found actual harm or worse (level G and above).
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J20.6% | K— | L— |
| Actual harm | G— | H— | I— |
| No harm, potential for more than minimal | D29194.2% | E123.9% | F20.6% |
| No harm, potential for minimal | A— | B20.6% | C— |
In the surveyor’s words
What an F551 citation says
One finding from each severity level, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Based on interview and record review the facility failed to ensure one of one resident (1) retained and exercised their right to revoke their Durable Power of Attorney (DPOA), failed to honor the resident's repeated requests to be discharged home in accordance with their wishes and preferences, and failed to include the resident in the care planning process which included discharge planning. These failed practices violated the resident's rights causing undue psychosocial distress and harm for Resident 1. …
Based on interview and record review, the facility failed to protect the rights for one of 25 sampled residents (Resident 3) when the facility disregarded Resident 3's right for autonomy (when healthcare providers, caregivers, or facility staff make decisions for a resident without their consent, input, or consideration of their preferences) to designate his own representative.This failure resulted in Resident 3's psychological distress, functional decline and loss of dignity.Findings: A review of Resident 3's admission Record (AR) indicated Resident 3 was readmitted to the facility in March 2026 with diagnoses which included dementia (a decline in memory, thinking and social abilities) and cerebrovascular disease (conditions that affect blood flow to the brain).During a review of Resident… …
Based on record review, and interviews with the Health Care Power of Attorney (HCPOA), the Resident Representative, staff, and the Medical Director, the facility failed to honor an immunization declination when Resident #376 was administered an influenza vaccine after her HCPOA had declined the vaccination. This was for 1 of 6 residents reviewed for vaccination status (Resident #376). The findings included: Resident #376 was admitted to the facility on [DATE]. Review of Resident #376's medical record revealed The Statutory Form Health Care Power of Attorney dated 3/2/21. The form indicated Resident #376 appointed her Health Care Power of Attorney (HCPOA) to act for her and in her name to make health care decisions for her. …
Fletcher Rehabilitation and Healthcare Center · North Carolina
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