Failure to Address Resident Grievances and Excessive Call Light Wait Times
Summary
The facility failed to adequately address resident grievances regarding excessive call light wait times for all 18 residents reviewed. Multiple residents reported waiting extended periods, ranging from 15 minutes to over two hours, for assistance after activating their call lights. Several residents described being left in soiled conditions, experiencing humiliation, discomfort, and emotional distress as a result. Interviews revealed that staff sometimes turned off call lights without providing the requested assistance, and residents felt their complaints were either ignored or not resolved. The facility's call light system was operational, but there were no visual indicators outside resident rooms or at the nurse's station, relying solely on a beeper system for staff notification. The DON and ADON confirmed that call light audits and monitoring, which had been implemented after a previous survey, were discontinued after a certain date with no explanation or documentation for the cessation. There was no specific facility policy or defined expectation for timely call light response, and staff education did not specifically address prompt call light answering. The ADON was unable to articulate a standard for reasonable response time, and the facility's in-service records did not include targeted training on this issue. Review of resident care plans and grievance records showed that many residents required substantial to maximal assistance with ADLs and were frequently incontinent, making timely response to call lights critical for their dignity and hygiene. Grievance forms documented repeated complaints about long wait times, with some forms lacking evidence of resolution or follow-up. In several cases, residents or their families reported that grievances were not addressed, and staff actions were limited to verbal reassurances or corrective actions without systemic improvement. The facility's policy on resident rights emphasized dignity and prompt grievance resolution, but the documented practices did not align with these standards.
Penalty
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A facility failed to initiate a grievance for concerns raised during a resident council meeting. Residents reported that concerns were not consistently resolved, including getting residents out of bed for meals and activities and shortages of washcloths and towels. Review of grievance logs showed no matching grievances, and the Activities Director stated a grievance should have been initiated.
Resident council meetings were not held regularly, and no minutes or meetings were found for an extended period. A resident said the council had not met consistently since new ownership, and an admin staff member said she had only arranged one meeting in the past three months and did not know where the minutes were. An admin nurse was unsure whether meetings were occurring, while the facility policy stated it supports residents' rights to participate in a Resident Council.
Resident Council Meetings Held Without Privacy: A confidential resident group meeting was normally held in an upstairs dining room that had no doors or solid walls separating it from the open nurses' station or nearby hallways. Residents said they did not feel able to speak freely because staff could hear them and people could walk in and out. The Activity Director said she continued using that space because it had always been held there, and the Administrator stated the meeting should have been held in a private area. The facility had no specific policy on Resident Council meeting privacy.
Resident council concerns were not thoroughly documented, effectively addressed, or resolved. Repeated complaints involved dietary issues, housekeeping, laundry, CNA cell phone use, poor room cleaning, wrong or wrinkled clothing, lack of notification about a spouse’s ambulance transfer, and frequent dining room closures. Residents and an LPN reported that the same problems kept recurring, the kitchen often ran out of items, menus were wrong, and food quality remained poor, while the DON and Administrator said the issues were addressed to the best of their ability.
A resident with dementia and other psychiatric and neurologic diagnoses developed bruising and swelling on the face after reportedly being hit by a hairbrush. CNA and LPN assessed the resident, and the physician and DON were notified. The resident’s family later raised concerns about the bruising, but the DON had no documented follow-up or resolution, and the family reported they never heard back about the concern.
Resident Council concerns were not properly acted on, documented, or resolved. Meeting minutes showed repeated complaints about late meal trays, shower frequency, tough meats, missing condiments, and food requests not being followed, but the grievance log had no entries for these issues and no grievance forms were completed. The Activity Director stated grievances were not done for Resident Council as a whole, and residents reported the concerns had not improved.
Failure to Initiate Grievance for Resident Council Concerns
Penalty
Summary
The facility failed to initiate a grievance for resident care concerns voiced during a resident council meeting. During an interview on 06/08/2026, resident council members stated the facility did not consistently provide resolutions to concerns discussed at council meetings. Review of the May 2026 resident council minutes showed concerns about getting residents out of bed for meals and activities and a shortage of washcloths and towels. Review of grievance logs from 02/2026 through 06/2026 showed no grievances corresponding to the concerns raised at the resident council meeting. Staff R, Activities Director, stated they did not initiate a grievance related to the residents' concerns but should have, and Staff A, Administrator, stated it did not meet expectations that specific concerns brought up in resident council had not been addressed and followed up on.
Resident Council Meetings Not Held Regularly
Penalty
Summary
The facility failed to facilitate and ensure the resident council was able to meet regularly. Record review of the Resident Council Meeting showed no minutes or meetings for the months of May 2025 through May 2026. A resident stated the Resident Council had not met on a regular basis since the new owners acquired the facility and reported that Administrative Staff A conducted a meeting in 02/26, though the resident could not remember the exact day. The resident also stated the activities directors previously facilitated the Resident Council meeting, but there had been several turnovers in the activity department and a Resident Council meeting had not occurred. An administrative nurse stated Administrative Staff A had held a meeting with residents and that the facility had turnover in the activity department, but she was unsure whether meetings were happening. Administrative Staff A stated she had arranged and assisted residents with one resident council meeting in the past three months and did not know where the minutes for that meeting could be found. The facility's Resident Council Meeting policy dated 02/01/26 stated the facility supports residents' rights to organize and participate in resident groups, including a Resident Council.
Resident Council Meetings Held Without Privacy
Penalty
Summary
The facility failed to provide a private meeting space for the residents' monthly council meetings for 11 of 11 confidential residents reviewed for resident council. During observation and interview on 05/20/2026 at 11:30 a.m., a confidential resident group meeting was held in a private therapy gym, and it was reported that the meeting was normally held in the upstairs dining room. The dining room had no doors or solid walls separating it from the open nurses' station or the two hallways leading into the area. Residents stated they did not feel they could express their opinions because staff could hear them and anyone could walk in and out of the dining room area. The Activity Director stated she had been hired in September 2025, knew the meeting should be held in a private area, but continued using the upstairs dining room because staff told her it had always been held there. The Administrator stated he expected the meeting to be held in a private area so residents could voice concerns and acknowledged the risk that the wrong person could hear something. The facility did not have a specific policy regarding privacy of Resident Council meetings.
Resident Council Concerns Were Not Consistently Documented or Resolved
Penalty
Summary
The facility failed to honor residents’ right to organize and participate in resident/family groups by not thoroughly documenting, effectively addressing, and resolving concerns raised in resident council meetings. Review of resident council minutes from 05/02/25 through 04/03/26 showed repeated complaints about dietary services, housekeeping, laundry, nursing communication, CNA cell phone use, room cleanliness, clothing being returned wrinkled or delivered to the wrong room, and residents not being notified about a spouse’s ambulance transfer. Several meetings also documented ongoing concerns that the dining room was closed, the kitchen ran out of items, menus were wrong, and food quality was poor. The facility’s Resident Council Follow-Up Summary showed multiple concerns marked closed or satisfied even though similar complaints continued in later council meetings. Some follow-up entries documented staff re-education, monitoring, or review of processes, but the same issues persisted across multiple months. There was no follow-up documentation provided for July 2025, August 2025, or January 2026, and the Administrator verified this on 05/07/26. At that time, education and monitoring that were stated to have been completed or started were requested but not provided to the survey team. During the resident council meeting on 05/06/26, multiple residents stated that the dining room was closed, the kitchen frequently ran out of items, menus were always wrong, medications were not available, and food quality remained poor. Residents stated they continued to report the same problems and that they were never fixed. The Administrator and DON stated they felt the issues were addressed to the best of their ability. Additional interviews on 05/07/26 confirmed ongoing unresolved concerns, including repeated dining room closures due to staffing, residents not being informed until mealtime, and dietary staff reporting frequent shortages of food items and unavailable menu items.
Family Concern About Resident Face Bruising Was Not Timely Addressed
Penalty
Summary
The facility failed to ensure that Resident #90’s family concerns about bruising and swelling on the resident’s face were addressed in a timely manner with resolution. Resident #90 was admitted on 09/22/25 and discharged on 04/07/26. Diagnoses included demyelinating disease of the central nervous system, cognitive communication deficit, unspecified dementia, alcohol abuse, unspecified psychosis, visual hallucinations, mood affective disorder, and need for help with personal care. The quarterly MDS assessment indicated intact cognition. After CNA #225 reported discoloration under the resident’s right eye and swelling on the right side of the face, LPN #261 assessed the resident, who denied pain and had vital signs within normal limits. The resident stated the hairbrush in her bag had hit her in the face while she was trying to retrieve it, and the physician and DON were notified. The resident’s family later expressed concerns to the DON about the bruising on Resident #90’s face, but the family reported there was no follow-up and they never heard back regarding the concern. The DON confirmed receiving a call from the family about the incident and stated she told them the resident had hit herself with her hairbrush, but she could not recall details of the call, the family’s response, or any documented follow-up or resolution. The RDCS confirmed that resident or family concerns should be investigated immediately and followed up with a call regarding the outcome, and confirmed this family concern was not addressed timely. Facility grievance policies stated grievances and complaints would be investigated, resolved, and the resident or representative informed of findings and corrective actions within 5 working days.
Resident Council Grievances Not Acted On or Logged
Penalty
Summary
The facility failed to act, respond, and resolve concerns raised by the organized Resident Council group for 1 of 1 resident council groups. Review of the facility’s grievance policy showed the facility was responsible for ensuring grievances were reviewed and addressed in a timely and appropriate manner, with resolution communicated and maintained, and for keeping records of complaints. However, review of Resident Council meeting minutes from January 2026 through April 2026 documented repeated concerns about meal trays arriving late, shower frequency, meat being hard to cut, not receiving condiments with meals, food requests not being followed, and wanting more fresh fruit options. The minutes also documented that residents were reminded to complete blue card grievance forms when experiencing issues. Review of the grievance log from January 2026 through April 2026 showed no entries for the Resident Council concerns, and no grievance forms were completed for those issues as required by the facility’s grievance policy. In interview, the Resident Council group stated the shower concerns had not improved and the food concerns with late meal trays, tough meats, and missing condiments had also not improved. Staff W, Activity Director, stated they did not do grievances for Resident Council as a whole, sometimes completed grievance cards for individuals, and sometimes residents said they would do it themselves; Staff W also stated the concerns were brought to the following month’s QAPI meeting. The Administrator stated the Activity Director had been educated on the grievance process for Resident Council, and later stated resident council grievances had been started with the most recent month and would go back as needed, but an updated grievance log was not provided.
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