Delayed Response to Resident Call Lights
Summary
The facility failed to ensure resident call lights were answered in a timely manner for multiple residents who reported prolonged waits for assistance. One resident with mild cognitive impairment stated she sometimes waited 45 minutes for staff to respond and reported having to search for staff when her urinary catheter bag was full. During a grievance review, the administrator checked the call light response screen and found the resident’s call light had been on for 12 minutes, and the call button remained on throughout the conversation until it was turned off after 26 minutes total. The resident also stated she wanted staff to acknowledge when they were busy and let her know they had seen her call light. Call light logs showed repeated extended response times for this resident, with 13 call light events ranging from 22 to 61 minutes over the reviewed period. Another resident, who was cognitively intact, filed grievances stating he waited about 1 hour for staff to answer his call light on two separate occasions. Facility review of the call bell report identified waits of 58 minutes on one grievance and a call light log showing a 110-minute wait on another. The resident’s call light logs also showed 13 events ranging from 21 to 71 minutes during the reviewed period. Additional resident interviews and call light logs showed similar delays for other residents. One resident reported call light waits of at least 30 minutes up to an hour and a half and said he sometimes had to stop waiting. Another resident said he took his cell phone to the bathroom and played games while waiting for staff, stating it could take two games of cribbage before staff entered. Call light logs for several other residents showed waits ranging from 20 to 80 minutes, and a nursing assistant stated the hall screens only showed which room numbers had call lights on, while the nurses’ station computer showed the exact time the lights were activated.
Penalty
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Resident Council meetings were held in the dining room instead of a private space, with staff and other residents coming in and out during the meetings. Residents stated they filtered what they said because of the lack of privacy, and the AD and Administrator both acknowledged the dining room was not private and that no sign was posted when council was in session.
Failure to support resident family group meetings: A facility handbook stated residents have the right to organize and participate in resident/family groups, but family council minutes did not show that families chose to stop meetings or that the facility formally told families the meetings would end. Family representatives said the meetings had previously occurred monthly or quarterly but were no longer being held, and the NHA and Activities Director confirmed the prior administration stopped them and that there was no formal communication to families.
Failure to support family group formation and track a family concern. A resident family member reported interest in starting a family council for the secured unit and said he contacted administration and the LTC ombudsman, but the facility did not assist him or provide information to help form the group. The concern was not entered on the concern log, and the ANHA confirmed the facility was aware of the issue but did not assist with forming the family group.
Grievance resolutions were not documented or communicated. During a resident council meeting, eight residents stated their grievances had not been resolved and that staff had not discussed resolutions with the council. Review of grievance records showed many complaints lacked documentation of resolution, complainant notification, and the method of communication. The Administrator identified herself as the grievance official and stated she expected grievances to be completed and followed up within 5 days, while the facility policy required a written decision for the person with the grievance.
A resident council meeting was interrupted three times when the BOM entered to retrieve a resident, returned to say the resident would not be back, and an Infection Control staff member entered regarding resident care. Residents stopped discussing meeting business during each interruption. The Activities Director Assistant said she did not know meetings should not be interrupted, the Activities Director said she had not told her about using a Do Not Disturb sign, and the DON acknowledged staff had not been adequately instructed. The Resident Council President stated interruptions had happened before and residents had become reluctant to discuss concerns because meetings were not consistently private.
Failure to investigate a Resident Council grievance regarding long call bell response times. Residents reported that some concerns get responses while others do not, and that staffing problems and agency staff not answering call bells were ongoing. Review of grievance logs showed no grievance form or investigation for the concern, and the NHA confirmed the issue had not been investigated.
Resident Council Held Without Privacy
Penalty
Summary
The facility failed to provide a private meeting space for Resident Council meetings for 7 of 15 confidential residents reviewed for resident rights. Record review showed Resident Council meetings were held in the dining room in February, March, April, May, June, and July 2026, with 4 to 6 residents present at each meeting. An observation on 8/12/26 at 11:00 AM showed staff and residents coming in and out of the dining room during the Resident Council meeting, and those individuals were not attending the meeting. During an interview on 8/12/26 at 11:00 AM, 7 alert and oriented residents who attended Resident Council stated the meetings were always held in the dining room, staff came in and out with no privacy, and they filtered what they said because staff were present. The Activities Director stated on 8/13/26 at 10:30 AM that Resident Council had been held in the dining room for the entirety of her 12-year employment, that the dining room was not private, and that no sign was posted for the meeting. The Administrator stated on 8/13/26 at 11:15 AM that she knew Resident Council was supposed to be held in a private setting, that it had always been held in the dining room during her 10 years of employment, and that the dining room was not private.
Failure to Support Resident Family Group Meetings
Penalty
Summary
The facility failed to assist resident families with forming and continuing a family group for three of three resident families identified in the report. The facility handbook stated residents have the right to organize and participate in resident groups, and that the facility must provide a resident or family group with private space and take reasonable steps, with the group’s approval, to make residents and family members aware of upcoming meetings. However, review of the family council minutes dated 8/20/25 showed families were informed of upcoming events, shared suggestions, and were told the next meeting would be announced later, while the minutes did not document that families had decided not to continue meetings or that the facility had communicated it would stop conducting Family Group meetings. Resident family interviews indicated the meetings were no longer being held. Two resident family representatives stated the facility no longer provided family meetings and had previously held them monthly, while another family representative stated the prior administrator stopped the quarterly meetings and that there had been no formal communication to families that the meetings were no longer occurring. The NHA stated August 2025 was the last Family Council meeting and that the prior administration did not want to continue the meetings, while the Activities Director stated the prior administrator stopped the meetings and that there was no formal communication to families. The report also states that information was disseminated to the NHA, DON, and Regional Director of Clinical Services that the facility failed to assist a resident family with forming a family group for four of four resident families as required.
Failure to Support Family Group Formation and Track Family Concern
Penalty
Summary
The facility failed to honor a resident family member’s right to organize and participate in a family group and failed to follow up on the family member’s concern. Resident Family R110 stated that in May 2026 he was interested in attending a resident group and starting a family group for the fourth floor. He reported that he spoke with administration and sent an email about the concern, but nothing had happened, and he had tried to work with the ombudsman but did not have contact information for other families and could not be on the unit continuously to locate them. He also stated that the facility did not assist him or provide information for starting a resident family group. Review of the resident rights agreement showed that a resident has the right to have family members or other resident representatives meet in the facility with the families or resident representatives of other residents. A letter from Resident Family R110 to the NHA stated that he had contacted the county LTC ombudsman about starting a Family Council for the secured nursing care unit and had discussed the idea with several family members who were interested in forming the council. However, the concern log from May 2026 to the current review did not include this concern. During interview, the ANHA stated that the NHA and ANHA were aware of the concern, that it was not included on the concern log, and that the facility did not assist Resident Family R110 with forming a family group.
Grievance resolutions were not documented or communicated
Penalty
Summary
The facility failed to ensure that resident grievances were addressed and that documentation of staff efforts to resolve those grievances was communicated to residents and approved as effective resolutions for eight residents who attended the resident council meeting on 7/29/26. During the meeting, residents 16, 30, 31, 63, 79, 81, 108, and 109 stated that their grievances had not been resolved and that staff had not come to the council or to any members to discuss grievance resolutions brought from the resident council. The residents reviewed included individuals with BIMS scores ranging from 11 to 15, indicating cognition that was intact for most and moderately impaired for one resident. Review of grievance records from May 2026 through July 2026 showed that 37 of 77 grievances did not have documented resolution, including the complainant notification and the method used to communicate the outcome. The Administrator stated on 7/30/26 that she was the grievance official responsible for reviewing and ensuring completion of grievances, and that she expected grievances to be resolved, completed, and followed up with the complainant within 5 days. The facility's March 2025 grievance policy stated that the Administrator oversees the grievance process, routes grievances to the appropriate department manager, and that the person with the grievance has the right to a written decision.
Resident Council Meeting Interrupted
Penalty
Summary
The facility failed to provide residents with a private location for a resident council meeting when the scheduled meeting was interrupted three times after it began. During the meeting, the Business Office Manager entered to retrieve a resident, returned later to say the resident would not be coming back, and then an Infection Control staff member entered regarding resident care. Residents stopped discussing meeting business during each interruption. During interviews later that day, the Activities Director Assistant stated she did not know meetings should not be interrupted and that she intended to begin placing a "Do Not Disturb" sign on the door for future meetings. The Activities Director stated she had not told her assistant about using a sign, and the DON acknowledged staff had not been adequately instructed to avoid entering resident council meetings. The Resident Council President stated interruptions had occurred previously and residents had become reluctant to discuss concerns because meetings were not consistently private.
Failure to Investigate Resident Council Grievance
Penalty
Summary
The facility failed to make ongoing efforts to resolve grievances presented by the Resident Council. Facility policy stated that grievances voiced during resident or family council meetings were to be recorded on a designated grievance form and addressed by the Grievance Official. Resident Council meeting minutes documented that residents raised concern that call bell response times were longer than ten minutes and were causing residents to have accidents. However, review of the grievance logs for June and July 2026 found no documented evidence that a grievance form was created or that the concern was investigated. During an interview, residents stated that some concerns receive responses while others do not, and that staffing remains a problem with agency staff sitting on their phones instead of providing care and answering call bells. The Nursing Home Administrator confirmed that the concern about long call bell wait times had been voiced at the Resident Council meeting and had not been investigated as of the date of interview.
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