Failure to Address and Resolve Resident Grievances Regarding Call Light Response and Water Pass
Summary
The facility failed to ensure that grievances raised by residents during Resident Council (RC) meetings were promptly documented, investigated, and resolved. Over several months, RC meeting minutes consistently recorded concerns regarding delayed call light response times, particularly on the third shift, staff turning off call lights before addressing residents' needs, and inconsistent water pass. Despite these recurring issues being documented as both old and new business in multiple RC meetings, the 'Actions taken' sections were frequently left blank or marked as 'ongoing,' with no clear evidence of resolution or follow-up. During an RC meeting, all nine participants confirmed that assistance was not provided in a timely manner on the third shift, with one resident reporting a wait of several hours for help after activating the call light. Residents expressed frustration that their repeated complaints were not being taken seriously by facility leadership, with some stating they had stopped voicing concerns to the Nursing Home Administrator (NHA) or Director of Nursing (DON) due to a lack of meaningful response. Several residents described receiving generic assurances without observable improvement, and the issues would temporarily improve before recurring. The NHA acknowledged awareness of the concerns and described a staffing schedule change, but the report does not indicate that these actions effectively addressed the residents' grievances.
Penalty
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The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
The facility failed over several months to respond to repeated resident council concerns about inadequate staff response to care needs, including delayed call light response, lack of licensed nurse involvement, insufficient staffing on units when CNAs took breaks together, late meals, and residents not being assisted to or from bed or the dining room in a timely manner. Residents reported being neglected or left unattended while staff used cell phones or earbuds for personal activities, with some residents left in soiled briefs, not fed, or waiting hours for transfers. A group of residents documented these issues in a signed letter, and during a group interview most residents stated that administration had not resolved these concerns. Facility documentation of its response did not demonstrate that staff were educated or instructed to correct the timeliness of care or the length of staff breaks, and the administrator acknowledged the failure to respond promptly to the resident council’s grievances.
The facility failed over many months to resolve and communicate actions taken on recurring concerns raised in Resident Council meetings. Residents repeatedly reported issues such as delayed and cold meals, inadequate shower frequency, unmade beds, missing or unwashed clothing, poor call light response, and noisy staff at night. Although some concerns were written on Resident Council Concern forms and assigned to nursing, dietary, housekeeping, or laundry, many forms were missing, incomplete, or lacked any description of what was done. Meeting minutes often had blank sections for follow-up or pending updates, and residents later reported that they were not informed about what, if anything, was being done to address their ongoing complaints, leading to a deficiency related to honoring residents’ rights to organize and participate in resident/family groups and have their concerns addressed.
The facility failed to act promptly on repeated Resident Council concerns about delayed call light response over multiple months. Residents reported that call lights often went unanswered for 25–60 minutes, that CNAs and nursing staff sat at the nurse’s station or in offices instead of responding, and that one resident waited an hour for help to use the bathroom while another, who could not remain in a diaper due to wound care needs, waited to be changed. Although the Activity Director and Regional Director of Operations described a process using Resident Council Action Forms to document and respond to such concerns, no action forms were completed or attached to the meeting minutes for several months in which these issues were raised, contrary to the facility’s Resident Council policy requiring timely response and Administrator monitoring.
The facility failed to document and communicate its response to repeated Resident Council complaints about cold meals, particularly breakfast items, over several months. Multiple cognitively intact residents reported voicing concerns about cold food and late meal service during Resident Council meetings, and being told by the Activities Director that the issues would be addressed, but they did not receive written grievance responses or follow-up. Meeting minutes for the relevant period reflected only general discussion and did not record these concerns, and there was no evidence of completed Resident Council grievance forms. The Activities Assistant and Activities Director confirmed that concerns were handled verbally, with the Activities Director unaware that documentation of Resident Council grievances and follow-up was required, and the Administrator acknowledged that concerns from these meetings were addressed verbally rather than in writing.
The facility failed to act promptly on repeated Resident Council concerns about confused, wandering residents entering other residents' rooms and disturbing them. Over several months, council minutes documented reports of residents entering rooms late at night, removing items, and roaming halls after being moved from a dementia unit, without documented resolution or follow-up. Individual and group interviews revealed that residents continued to experience confused residents entering their rooms daily, taking food and personal items, and in one case grabbing and pushing a resident's wheelchair, while staff response was described as minimal and largely limited to verbal redirection. Residents also reported suggesting the use of stop signs across doorways during council meetings but stated they had not received the signs or any response to this request.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Failure to Respond to Resident Council Concerns About Inadequate Staff Response
Penalty
Summary
The deficiency involves the facility’s failure to respond to resident council concerns and grievances regarding inadequate staff response to care needs over a six‑month period. Resident council minutes from multiple meetings documented repeated complaints about delayed call light response times, lack of licensed nursing response, insufficient staff on units due to nurse aides taking breaks together, late meals, and residents not being assisted out of bed or to and from bed in a timely manner. Additional concerns included nurse aides being too busy to complete restorative care, staff not checking on residents, and residents not being assisted from the dining room after the evening meal. A facility‑provided letter signed by nine residents further described residents being neglected, dismissed, or left unattended by aides or employees who were frequently using cell phones or earbuds for personal activities instead of providing care. The resident letter also reported residents being left in the dining room until late in the evening while aides sat in breakrooms using their phones, residents not being fed, residents left in soiled briefs, and residents waiting hours to be transferred from wheelchairs to beds. It described aides carrying hot plates in one hand and cell phones in the other while residents waited, and aides vaping in hallways and in the employee bathroom. During a resident group interview, nearly all participating residents voiced ongoing concerns that facility administration had not resolved these issues related to inadequate staff response to care needs. The facility’s later documentation of its response to resident council concerns did not show that staff had been instructed or educated to address the timeliness of getting residents out of bed or the length of staff breaks, and by the end of the survey, evidence of such education or instructions was not provided. The Nursing Home Administrator confirmed that the facility failed to respond to resident council concerns and failed to do so in a timely manner for the entire review period.
Plan Of Correction
A Family Council meeting is scheduled for May 8th at 4:30 pm with the Management staff to discuss concerns regarding call light response, resident transfer status and bed mobility this is a new intervention to improve communication with families The follow-up of these conversations/concerns will be documented by the Social Worker in the appropriate location and in a timely manner. A Family Council meeting will be scheduled monthly The DON has created an assignment sheet that will clearly inform staff when, how long, and where their break time can be taken. Staff will be educated by the DON/Designee on the Call light policy and the new assignment sheet, which will show the scheduled break time of staff including how long the break will be. Education will be provided to the staff responsible for resident council and how to address concerns brought up in the meetings Audits will be completed by the DON/Designee on the call light policy, the new assignment sheet and timely response to council concerns weekly times four and monthly times two. Results of these audits will be reviewed by the QAPI committee for further recommendations.
Failure to Resolve and Communicate Resident Council Concerns
Penalty
Summary
The deficiency involves the facility’s failure to resolve and communicate actions taken on concerns and suggestions raised during Resident Council meetings over a period of 10 of 11 reviewed months. Resident Council minutes from February 2025 through January 2026 repeatedly documented resident complaints about showers not being provided as often as desired, food being served late, cold, raw, burnt, or of poor quality, beds not being made, and clothing not being taken to or returned from laundry. Although some Resident Council Concern forms were completed and assigned to departments such as nursing, dietary, and laundry, many forms lacked documentation of what was done to address the concerns, and several months had no concern forms at all despite documented complaints in the minutes. Across multiple months, the Resident Council minutes showed recurring issues without clear follow-up or documented resolution. In February 2025, residents reported late and cold meals, undercooked food, missed showers, unmade beds, and missing or unwashed clothing; concern forms were created for dietary and nursing, but one form had no description of actions taken and another only contained a signature and date. In March and April 2025, residents again voiced concerns about showers, bed-making, missing clothing, and poor or late meals, yet the facility could not provide any corresponding Resident Council Concern forms. In May 2025, residents added complaints about call bells not being answered for long periods, inadequate room cleaning, ill-fitting bed sheets, small or unappetizing food portions, and lack of requested sandwiches; while some concern forms were completed with general departmental responses, the minutes’ “Pending Updates” sections were often blank, and there was no documentation that specific resolutions were communicated back to residents. From June through November 2025 and into January 2026, the same categories of concerns—call light response times, staff turning off call lights without providing care, noisy or disruptive staff at night, insufficient showers, inadequate linens and towels, missing clothing, and dissatisfaction with food quality, variety, and timeliness—continued to appear in the Resident Council minutes. For several of these months (June, July, August, September, October, and November 2025), the facility was unable to produce any Resident Council Concern forms despite documented complaints. When concern forms were completed in January 2026 for laundry, nursing, and dietary issues, some contained only a generic statement that labeled clothing was returned daily, and others were left entirely blank for the department response, signature, and date. During a Resident Council group interview, multiple residents agreed that concerns about call bell response times, cold or late food, and missing clothing were recurring and ongoing, and they stated that Resident Council was never provided communication about what was done or being done to address these issues. The Activity Director and Administrator confirmed that concerns were frequently repeated month to month and acknowledged that the documented department responses often did not truly address the issues raised, and that the expected process of documenting and reporting back resolutions in the minutes was not consistently carried out. The deficiency centers on the facility’s failure to honor residents’ rights related to Resident Council by not effectively resolving and communicating the handling of concerns raised in these meetings. The Resident Council minutes repeatedly documented the same categories of complaints without clear evidence that the facility investigated, resolved, and reported back on these issues in a systematic way. Missing or incomplete Resident Council Concern forms, blank sections for pending updates, and resident reports that they were not informed of any actions taken demonstrate the inaction and lack of communication that led to the cited deficiency.
Failure to Address Repeated Resident Council Concerns About Call Light Response
Penalty
Summary
The deficiency involves the facility’s failure to promptly address and follow up on resident concerns about delayed call light response that were repeatedly raised in Resident Council meetings over several months. During a Resident Council meeting held on 03/24/2026, residents reported that call lights were not answered in a timely manner and that it sometimes took up to an hour to receive assistance. Review of Resident Council meeting minutes showed that in August 2025 residents reported nursing staff were sitting in the office discussing personal matters instead of answering call lights, and that on one station it was taking 45 minutes to an hour to respond. In September 2025, residents stated they felt CNAs sat at the nurse’s station, did not respond to call lights, forgot to return, and told residents they did not have time. In October 2025, residents reported one resident waited from 11:30 p.m. to 12:30 a.m. for help to go to the bathroom, another resident waited 25 minutes for help, and another resident waited for someone to change her despite being unable to remain in a diaper due to wound care needs. In December 2025, residents again reported staff were not responding to call lights in a timely manner and that they were waiting longer than 15 minutes for assistance. Interviews and record review showed that the facility did not complete or document required follow-up to these concerns as outlined in its own Resident Council policy. The Activity Director stated she typed up concerns voiced at Resident Council meetings and distributed them to each department using a Resident Council Action Form, then attached the completed forms to the corresponding meeting minutes. The Regional Director of Operations stated that concern forms were to be completed after each Resident Council meeting, distributed to the appropriate departments, and the responses documented on the forms, which were then filed with the meeting minutes for review with residents at the next meeting. However, there were no Resident Council Action Forms completed for the August, September, October, or December 2025 meetings to show that the residents’ call light concerns were addressed. The facility’s policy “GUIDELINES FOR RESIDENT COUNCIL,” dated 06/20/2023, states that residents have the right to be involved in decisions affecting their lives, that group concerns require a timely response and resolution that satisfies the group, and that the Administrator monitors this process. The lack of completed action forms for these months demonstrates the facility’s failure to act promptly on and document resolution of the Resident Council’s call light concerns.
Failure to Document and Follow Up on Resident Council Food Temperature Complaints
Penalty
Summary
The deficiency involves the facility’s failure to document and communicate its efforts to address concerns raised in Resident Council meetings, specifically regarding repeated complaints of cold food. Review of Resident Council minutes from three meetings showed only "open discussion" with no recorded concerns about cold food, despite multiple residents reporting that such concerns were voiced. There was no written evidence from December 2025 through February 2026 demonstrating the facility’s response to grievances or recommendations made by the Resident Council. One cognitively intact resident, serving as Resident Council President, reported that during the February Resident Council meeting she complained about cold food, specifically grits that were not warm enough for cheese to melt. She stated the Activities Director told her the concern would be addressed with the Dietary Manager but did not specify when, and the Resident Council never received any follow-up from either the Dietary Manager or the Activities Director. Another cognitively intact resident reported attending Resident Council meetings regularly and stated she had voiced concerns on several occasions, including during the January meeting, about cold food at breakfast and dinner. She reported submitting a verbal complaint to the Activities Director and was told the concern would be looked into, but she did not receive any grievance response or follow-up. A third cognitively intact resident reported regularly receiving cold breakfast meals and that breakfast was often served late, and stated these concerns were discussed during the December, January, and February Resident Council meetings. The Activities Assistant, who supported Resident Council meetings, stated the Activities Director was responsible for documenting resident concerns and acknowledged hearing concerns about cold coffee and food months earlier, but was unsure if they were documented or if a Resident Council grievance form was completed. The Activities Director confirmed she led the meetings and was responsible for the minutes, acknowledged hearing occasional concerns about cold food, and stated she verbally notified department heads and the Administrator but did not document concerns in the minutes or through the grievance process because she was unaware documentation was required. The Administrator stated he was aware of cold food concerns the prior year and that concerns after Resident Council meetings were addressed verbally, not in writing.
Failure to Act on Resident Council Concerns About Wandering Residents Entering Rooms
Penalty
Summary
The facility failed to honor residents' rights to have their views considered and acted upon regarding ongoing concerns about confused, wandering residents entering other residents' rooms. Facility policy stated that the Activity Director would attempt to accommodate resident recommendations and provide follow-up to the Resident Council, and that resident issues would be documented and forwarded to the Administrator for appropriate follow-up. Resident Council minutes over three consecutive months documented repeated concerns: in December, residents reported confused residents going into other rooms late at night with no resolution documented; in January, residents again reported wandering and removal of items from rooms, with a documented plan for staff education and purposeful rounding; and in February, the minutes did not show any review or follow-up of the prior wandering concern to determine if it had been resolved. Residents later reported that they had suggested using stop signs across doorways during a council meeting but had not received any response or implementation. Multiple resident interviews corroborated that the problem persisted. One resident reported that residents moved from the dementia unit to another hall were confused, roamed hallways, entered her room, and became more agitated and hostile when redirected; she described an incident where a confused resident grabbed her wheelchair from behind and began pushing her until staff intervened. Other residents reported that confused residents roamed into their rooms, attempted to take items that did not belong to them, and took food from meal trays. A bedbound resident stated that a confused resident frequently entered her room, appeared to mistake her for a family member, and took her snacks, and she had not completed a grievance form. In a group interview, several residents stated that wandering residents entered their rooms daily, hit and stole from residents, and that staff response was limited to telling the wandering residents to move on. Residents also reported that, despite raising these issues monthly since December and suggesting stop signs for doors, they had not received the signs or any substantive response from administration, demonstrating a failure to act promptly on resident council concerns about quality of life and wandering behaviors.
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