Failure to Resolve Ongoing Resident Concerns with Dietary, Call Bell Response, and Staff Conduct
Penalty
Summary
The facility failed to address and resolve ongoing concerns raised by residents during Resident Council meetings over a period of at least one year. Documented issues included repeated complaints about dietary services, such as dissatisfaction with food taste, inconsistent availability of certain items (e.g., eggs), improper food temperature, and poor food presentation with liquids from vegetables mixing with other foods. Residents also reported persistent problems with extended call bell wait times, including an incident where a resident waited 20 minutes and nearly fell, as well as concerns that call bells were being turned off at the nurses' stations. Additional complaints included difficulty locating staff for assistance, staff taking breaks simultaneously, staff using cell phones on the units, and a staff member being found sleeping in a cubby. Residents also reported staff using inappropriate or foul language and excessive noise levels created by staff. Despite these ongoing concerns being documented in Resident Council minutes and brought to the attention of facility leadership, including the Administrator and DNS, the issues persisted over multiple months. The facility's Concern, Complaint and/or Grievance policy directs that concerns should be actively resolved, but the repeated nature of the complaints indicates that effective resolution did not occur. Interviews with facility leadership confirmed awareness of the issues and acknowledged that in-services and monitoring had taken place, but the same concerns continued to be reported by residents.