Failure to Address Resident Council Concerns Over Prolonged Call Light Response Times
Summary
The facility failed to effectively address and resolve concerns raised by the Resident Council regarding prolonged call light response times. During a meeting with the surveyor, all seven residents present confirmed that the Resident Council had repeatedly complained about long wait times for call lights to be answered, with two residents reporting ongoing delays. One resident specifically stated he had waited as long as an hour for assistance in recent weeks. Review of Resident Council meeting minutes showed that these concerns had been documented multiple times over the past year. The Executive Director (ED) acknowledged awareness of the issue and identified two potential causes: the call light system required a 2-3 second hold to reset, and some staff ignored alarms, assuming they had already been addressed. Although the facility had included call light response times in its QAPI meetings and implemented Performance Improvement Projects (PIPs) in response to complaints, the problem persisted. The ED reported that staff had been educated on the system, but could not provide documentation of this education. Additionally, interventions such as running daily call light reports and having administrators monitor pagers were implemented, but there was no monitoring during evening and night shifts, and staff did not follow up with residents who experienced long wait times. A review of call light reports revealed numerous instances where response times exceeded 30 minutes, with several cases surpassing one or even two hours. The ED was unable to define a reasonable maximum response time, stating it would vary depending on staff workload. Despite repeated interventions and ongoing monitoring, the facility did not resolve the issue, and residents continued to experience significant delays in call light responses.
Penalty
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The facility failed to adequately address repeated resident council concerns about limited snack variety and consistently cold food. Over many months, residents with various medical conditions, including dementia, CKD, pulmonary disease, and dysphagia, repeatedly reported that snacks lacked variety and that meals were often served cold in both rooms and the dining area. Concern forms generated from council meetings were incomplete or failed to address all issues raised, and residents stated they were not offered additional snack options or information on available items. The Activity Director confirmed that these concerns were ongoing and frequently reported, while also acknowledging a lack of knowledge about any effective actions taken to resolve the problems, despite a policy requiring written administrative responses to council concerns.
The facility failed to investigate or respond to repeated food-related complaints raised through resident Food Committee meetings, including concerns about food quality, temperature, portion sizes, presentation, menu variety, use of Styrofoam, lack of fresh bread, unannounced substitutions, and inconsistent snack service. Meeting minutes over several months documented ongoing dissatisfaction, yet there was no evidence of a plan of action, follow-up, or feedback to residents. The Dietary Manager and Administrator acknowledged awareness of complaints and confirmed there was no tracking system for resolution, while the Ombudsman reported multiple unresolved food complaints. Several residents reported being served burnt or tough food, unwanted substitutions, cold meals, plastic silverware, and repetitive menus, and stated that despite voicing concerns in resident groups, nothing changed.
Nine residents raised concerns about delayed medication administration, staffing, and continuity of care during a council meeting. The facility did not document specific details of these concerns or provide evidence of follow-up or action taken in response, and repeated requests for such documentation from the administrator were not answered.
The facility did not resolve repeated resident council complaints about cracks and holes in the driveway, resulting in incidents where residents in wheelchairs became stuck. Despite ongoing reports to administration and staff, concerns were not addressed in a timely manner, and residents felt their issues were ignored.
The facility did not respond to concerns raised by residents during council meetings, including issues with dietary services, late medication administration on weekends, improper medication handling, and ill-fitting bed sheets. Two residents reported that their concerns were repeatedly brought up without action, and the administrator confirmed a lack of evidence showing staff response.
Residents repeatedly raised concerns during council meetings about delayed call light responses, staff rudeness, cold showers, and requests for additional smoking breaks, but these issues remained unresolved for several months. Residents also reported that their requests to meet without staff and have a resident take meeting minutes were not accommodated. Staff interviews confirmed that these concerns were not addressed in a timely manner, and the facility's required documentation and follow-up process was not effectively implemented.
Failure to Address Repeated Resident Council Concerns About Snacks and Food Temperature
Penalty
Summary
The deficiency involves the facility’s failure to adequately address and respond to recurring concerns raised in resident council meetings regarding snack variety and food temperatures, affecting four cognitively intact or impaired residents with multiple medical conditions, including atrial fibrillation, pulmonary disease, dementia, chronic kidney disease, vascular disease, and dysphagia. Resident council minutes over approximately a one‑year period documented repeated complaints about limited snack options and cold food at meals. Despite these concerns being voiced at multiple meetings, the corresponding concern forms were incomplete or failed to address all issues raised. For example, some forms did not mention food temperature concerns at all, others only partially addressed snack variety, and some did not address either the lack of snack variety or cold food. Residents reported that they had asked for more variety in chips and fruit and had not been offered choices or a list of items available from the supplier, and they stated that the facility gave excuses for the continued reliance on peanut butter sandwiches. Residents also reported that food was consistently served cold both in their rooms and in the dining room. The Activity Director confirmed that resident concerns were documented in council minutes and that concern forms were written and given to department heads, but acknowledged that residents had consistent, repeated concerns about snack variety and cold food over the majority of the months reviewed. The Activity Director denied knowledge that the requested variety of snacks was ever offered, denied knowledge of what the facility was doing to improve food temperatures, and was unaware of any test trays being completed or results shared with residents. The facility’s own policy stated that administration shall respond in writing to concerns and recommendations raised by the resident council, yet the repeated, unresolved complaints and incomplete concern forms demonstrated that resident council concerns were not consistently or effectively addressed.
Failure to Address Repeated Food Committee Complaints and Resident Group Concerns
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to organize and participate in resident/family groups by not investigating, addressing, or implementing corrective actions for repeated food service complaints raised through the Food Committee. Review of Food Committee minutes from November 2025 through January 2026 showed multiple ongoing complaints about food quality, temperature, portion sizes, presentation, menu variety, use of Styrofoam, lack of fresh bread, dislike of certain foods, inconsistent snack pass, and lack of coffee availability. Meeting minutes from several dates documented concerns about meals being served cold, limited alternatives for resident preferences, repetitive menus, and dissatisfaction with the amount and type of pasta served, as well as food being overcooked or undercooked. Despite these recurring issues, there was no documented plan of action, investigation, follow-up, or feedback to residents in the Food Committee records. Interviews further confirmed the lack of response to resident group concerns. The Dietary Manager acknowledged awareness of some complaints but could not provide documentation of investigations, changes to food service practices, or communication back to residents. The Ombudsman reported multiple food complaints from several residents, including burnt lasagna, lack of fresh bread, unannounced food substitutions, and use of Styrofoam plateware, and stated she had exhausted all avenues with management. The Administrator confirmed there was no tracking system to ensure food-related complaints raised through the Food Council were followed up and resolved. Individual residents reported being served burnt lasagna with an unrequested substitution of mashed potatoes and gravy, food sometimes being cold, lack of fresh bread, dissatisfaction with plastic silverware, tough food that was difficult to cut, too many sandwiches, and a snack cart that was inconsistently passed with no variety. Residents stated they attended Resident Council and Food Committee meetings to voice concerns but saw no changes, affecting 15 identified residents and potentially all residents receiving food from the kitchen.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to promptly address grievances related to resident care that were raised during a resident council meeting attended by nine residents. Concerns were voiced regarding untimely medication administration, staffing, and continuity of care. The meeting minutes referenced additional details on the back of the form, but no further information was provided, and there was no documentation specifying the exact nature of the concerns about staffing and continuity of care. There was also no evidence that the facility followed up to clarify or address these concerns, nor was there any documentation of actions taken in response. Requests for evidence of follow-up or action from the facility administrator on three separate occasions went unanswered.
Failure to Address Resident Council Concerns About Unsafe Driveway
Penalty
Summary
The facility failed to address and resolve concerns raised by the resident council regarding the condition of the facility driveway, which was repeatedly reported as having cracks and holes. Resident council meeting minutes documented ongoing complaints over several months about the driveway's poor condition, including specific incidents where residents in wheelchairs became stuck in the cracks. Residents expressed frustration that their concerns were not being addressed or resolved by administration, despite being reported multiple times. Interviews with residents and staff confirmed that complaints submitted to the administration were not answered in a timely manner, if at all. The Activity Director, who facilitated the council meetings, stated that she relayed concerns to the Administrator but acknowledged that responses were lacking. The facility's policy indicated that resident council feedback should be reviewed by the QAPI committee, but there was no evidence that the concerns about the driveway were resolved or appropriately addressed.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to respond to concerns raised by residents during Resident Council meetings, as evidenced by a review of meeting minutes and staff interviews. Specific issues documented included complaints about the dietary department, late administration of medications on weekends due to nurses assisting aides, nurses leaving medications at the bedside, and sheets not fitting larger beds. Despite these concerns being recorded in the Resident Council Meeting Minutes, there was no evidence that the facility took action to address them, except for a note that more blue sheets for larger beds were provided on one occasion. Interviews with two residents who regularly attended the meetings confirmed that multiple concerns had been brought up each month without any resulting action. The facility administrator also verified the absence of documentation or evidence showing that staff had responded to the issues raised during the meetings. This deficiency was identified during an investigation under a specific complaint number and affected at least two residents out of the four reviewed for Resident Council participation.
Failure to Address and Resolve Resident Council Concerns in a Timely Manner
Penalty
Summary
The facility failed to address and resolve resident concerns raised during Resident Council meetings in a timely manner, as evidenced by repeated documentation of unresolved issues in the council minutes over several months. Concerns included call lights not being answered promptly, requests for an additional smoking break, cold showers in a specific wing, and staff speaking rudely to residents. These issues were consistently brought up in meetings from January through May, with no documented resolution or satisfactory response provided to the residents. Interviews with residents who held leadership roles in the Resident Council revealed ongoing dissatisfaction with the administration's handling of their complaints. The residents reported that their requests, such as having a resident take meeting minutes and meeting without staff present, were not accommodated. They also expressed frustration that their concerns about staff behavior, call light response times, and environmental issues like shower temperature had persisted for months without resolution. Staff interviews confirmed that the concerns raised by residents were not being resolved in a timely manner. The Activities Director acknowledged that resident training to take minutes had not been completed, and the Administrator confirmed that issues such as call light response, staff rudeness, and environmental complaints remained unresolved. The facility's policy required documentation and follow-up on resident concerns, but the process was not effectively implemented, as evidenced by the lack of resolution and ongoing resident dissatisfaction.
Plan Of Correction
maintain ongoing compliance LNHA will audit Resident Council Minutes and Concern forms weekly X4, then monthly x2 to ensure concerns are being resolved timely and appropriately. Results of the audits will be forwarded to the facility QAPI committee for further review and recommendation. F600 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 07/30/25 as the facility's allegation of compliance date. The facility failed to ensure residents were safe from abuse, affecting one resident #24. Step 1 Resident #24 was assessed and no negative findings. Resident assessment completed on 6/11/25 by NP. STNA #240 was removed from duty and suspended, personnel file for STNA #240 was reviewed for background check, along with 5 other random staff personnel files, no concerns were identified. Audit completed on 6/6/25. Step 2 To identify other residents that have the potential to be affected, on 6/6/25 the Social Services initiated interviews of those residents able to be interviewed regarding abuse, completing the interviews on 6/6/25 with no negative findings. DON completed skin check on 6-6-25 for non-verbal and cognitively impaired resident with no negative findings. Step 3 To prevent this from recurring, NHA started in house
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