Failure to Resolve and Communicate Resident Council Concerns
Summary
The deficiency involves the facility’s failure to resolve and communicate actions taken on concerns and suggestions raised during Resident Council meetings over a period of 10 of 11 reviewed months. Resident Council minutes from February 2025 through January 2026 repeatedly documented resident complaints about showers not being provided as often as desired, food being served late, cold, raw, burnt, or of poor quality, beds not being made, and clothing not being taken to or returned from laundry. Although some Resident Council Concern forms were completed and assigned to departments such as nursing, dietary, and laundry, many forms lacked documentation of what was done to address the concerns, and several months had no concern forms at all despite documented complaints in the minutes. Across multiple months, the Resident Council minutes showed recurring issues without clear follow-up or documented resolution. In February 2025, residents reported late and cold meals, undercooked food, missed showers, unmade beds, and missing or unwashed clothing; concern forms were created for dietary and nursing, but one form had no description of actions taken and another only contained a signature and date. In March and April 2025, residents again voiced concerns about showers, bed-making, missing clothing, and poor or late meals, yet the facility could not provide any corresponding Resident Council Concern forms. In May 2025, residents added complaints about call bells not being answered for long periods, inadequate room cleaning, ill-fitting bed sheets, small or unappetizing food portions, and lack of requested sandwiches; while some concern forms were completed with general departmental responses, the minutes’ “Pending Updates” sections were often blank, and there was no documentation that specific resolutions were communicated back to residents. From June through November 2025 and into January 2026, the same categories of concerns—call light response times, staff turning off call lights without providing care, noisy or disruptive staff at night, insufficient showers, inadequate linens and towels, missing clothing, and dissatisfaction with food quality, variety, and timeliness—continued to appear in the Resident Council minutes. For several of these months (June, July, August, September, October, and November 2025), the facility was unable to produce any Resident Council Concern forms despite documented complaints. When concern forms were completed in January 2026 for laundry, nursing, and dietary issues, some contained only a generic statement that labeled clothing was returned daily, and others were left entirely blank for the department response, signature, and date. During a Resident Council group interview, multiple residents agreed that concerns about call bell response times, cold or late food, and missing clothing were recurring and ongoing, and they stated that Resident Council was never provided communication about what was done or being done to address these issues. The Activity Director and Administrator confirmed that concerns were frequently repeated month to month and acknowledged that the documented department responses often did not truly address the issues raised, and that the expected process of documenting and reporting back resolutions in the minutes was not consistently carried out. The deficiency centers on the facility’s failure to honor residents’ rights related to Resident Council by not effectively resolving and communicating the handling of concerns raised in these meetings. The Resident Council minutes repeatedly documented the same categories of complaints without clear evidence that the facility investigated, resolved, and reported back on these issues in a systematic way. Missing or incomplete Resident Council Concern forms, blank sections for pending updates, and resident reports that they were not informed of any actions taken demonstrate the inaction and lack of communication that led to the cited deficiency.
Penalty
Resources
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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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