Failure to Resolve Resident Grievances on Condiments and Call Light Response
Penalty
Summary
The facility failed to promptly resolve grievances raised by residents regarding the lack of condiments during meals and delayed call light response times. Resident Council meeting minutes from October and November 2024 documented ongoing concerns about the absence of basic condiments such as salt, pepper, and butter. Observations confirmed that residents were served meals, including baked potatoes and roast beef, without condiments, and no salt or pepper shakers were present in the dining area. Staff interviews revealed that the dietary department had run out of condiments due to a delivery issue, and no alternative arrangements were made to provide these items to residents. Residents also reported significant delays in call light response times, with some stating that it could take up to 20 or 30 minutes for staff to respond, particularly during the overnight shift. Multiple residents described situations where staff would turn off call lights and promise to return but failed to do so, leading to unmet needs. One resident reported having to call 911 for assistance after her call light was ignored for an extended period. The Ombudsman corroborated these concerns, noting that CNAs were frequently not present or visible on the units during her visits. Interviews with facility staff, including the Social Services Director and Activities Director, confirmed that grievances about food service and call light response times were common and had been documented. However, these grievances were not resolved in a timely manner, as required by facility policy and resident rights regulations. The ongoing nature of these issues, as reported by residents and staff, demonstrated a failure to address and resolve resident concerns promptly.