Failure to Address Resident Council Concerns Timely and Appropriately
Penalty
Summary
The facility failed to address resident concerns raised during resident council meetings in a timely and appropriate manner. Multiple residents reported ongoing issues such as delayed call light responses, problems with smoke breaks, untimely showers and incontinence care, lack of activity variety, and insufficient staff responsiveness. These concerns were repeatedly brought up at council meetings over several months, with residents and staff confirming that the same issues persisted without satisfactory resolution. Documentation of concerns and follow-up actions was inconsistent or missing, and when forms were completed, they often lacked detail regarding the actions taken or plans for monitoring compliance. Record reviews showed that concern forms were either incomplete, missing, or failed to provide evidence of audits, interviews, or specific corrective actions. For example, audits claimed to have been performed to check call light response times and incontinence care, but the facility could not provide supporting documentation. In some cases, responses to concerns simply stated that more information was needed, without indicating any steps taken to resolve the issues. Additionally, concerns about staff behavior, pain medication administration, and food choices were either inadequately addressed or not documented at all. Interviews with residents, the Activity Director, and the Administrator confirmed that the same topics were repeatedly discussed at council meetings without effective resolution. The Administrator acknowledged the lack of detailed documentation and missing concern forms, as well as the inadequacy of responses that did not demonstrate corrective action. The ongoing nature of these unresolved concerns affected several residents who regularly attended the council meetings, as reflected in the facility's census and meeting records.