Failure to Track, Resolve, and Communicate Resident Council Grievances
Summary
The deficiency involves the facility’s failure to resolve and communicate outcomes of concerns raised through Resident Council meetings over an extended period. Review of the grievance logs from April 2025 through March 2026 showed that no grievances were filed on behalf of the Resident Council from April 2025 through December 2025, despite multiple documented concerns in the Resident Council minutes. When grievances began to be logged in January, February, and March 2026, there was no documentation of the specific complaints, plans to resolve them, or actions taken. Resident Council minutes across multiple months documented repeated grievances related to housekeeping, dietary, and nursing services, but the minutes generally did not show the facility’s responses to concerns voiced at prior meetings. Resident Council minutes from April 2025 through November 2025 showed recurring issues. In April 2025, residents reported housekeeping problems such as bathrooms not consistently cleaned, delayed trash removal, and slow laundry services; dietary issues including missing tray items, incorrect or incomplete meals, and unavailable alternatives; and nursing concerns such as delayed response to emergency call lights and nursing assistants’ reluctance to assist across halls. In May and June 2025, residents continued to report inconsistent room cleaning, delays in receiving basic supplies, cold and bland meals, missing tray items, and incomplete room cleaning and laundry delays, with no documented facility response to the previous month’s grievances. In July and August 2025, residents again raised unresolved dietary complaints, poor food quality, nurse aides’ reluctance to assist, unprofessional or negative staff attitudes, improper disposal of soiled briefs, and bathrooms not consistently stocked with toilet paper, with minutes still lacking documentation of how prior concerns were addressed. In subsequent months, similar patterns persisted. September and October 2025 minutes documented ongoing concerns about staff disposing of used briefs in resident trash cans, medication accuracy, poor staff attitudes, and shower schedules not being followed, with either no documented response or only general references to “updates” without details. November 2025 minutes noted that nursing had addressed issues such as briefs thrown on the floor, medication accuracy, negative staff attitudes, and medication timeliness, but there was no documentation of the facility’s specific responses. In January 2026, residents reported ongoing issues with staff attitudes, soiled briefs left in trash cans, medication accuracy, missing personal belongings, inconsistent showers, and delayed call light response, with no documented follow-up from November’s grievances. February 2026 minutes stated that all concerns had been documented and forwarded to departments, including missing belongings, inconsistent showers, staff attitudes, medication accuracy, dirty briefs in trash cans, delayed call light response, and staff using phones during work, but again lacked documentation of the facility’s responses. In March 2026, dietary concerns about inconsistent portion sizes and nursing concerns about excessive night-shift noise were recorded, with the Old Business section marked “Resolved” without further explanation. Resident interviews during the April 1, 2026 Resident Council meeting revealed that multiple residents, including the Resident Council President, agreed they were never provided information about what was being done to address their concerns and did not receive written communication regarding outcomes. Several residents reported feeling ignored, that their voices did not matter, and that they were frustrated by raising the same concerns repeatedly without follow-up or resolution. The Activity Director stated she organized the meetings, took minutes, and verbally communicated concerns to department heads and the Social Service Manager, but acknowledged she never received written documentation of investigations or outcomes and that, after a change in the grievance process in December 2025, she no longer received updates regarding grievance outcomes. The Social Services Manager, who served as the Grievance Official, acknowledged he had not been recording Resident Council grievances on the grievance logs until January 2026, tracked resolution by reviewing subsequent Resident Council minutes, and did not receive written notification of resolutions, instead assigning a standard 14-day resolution date. These actions and omissions resulted in a lack of documented investigation, tracking, and communication back to the Resident Council regarding the concerns raised over the 11 of 12 months reviewed. When asked, the Activity Director indicated that she stopped getting updates regarding the outcomes of grievances after the grievance process changed in December 2025.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Unresolved Resident Council Dietary Concerns: Residents repeatedly voiced ongoing food and meal service complaints, including unmet preferences, late meals, missing snacks, and inconsistent tray delivery. Council minutes showed the same dietary issues carried forward month after month without clear resolution, while residents and the Dietary Mgr confirmed the concerns continued despite repeated discussion with facility leadership.
A resident with cognitive impairment, mood disorder, and anxiety reported that a nurse aide would lay on her in bed at night. Another aide later confirmed the resident had told her this concern and said she did not report it to administration because she did not believe it was plausible. The DON and Administrator stated that any staff member receiving such a report was expected to notify administration.
Resident Council grievances about weekend housekeeping and unlabeled or missing clothing items were not effectively resolved or communicated. Meeting minutes documented repeated concerns over two months, and residents stated their grievances were not being addressed. The Activities Director said she relied on others to handle and report back on grievances, while the DON was unaware of any Resident Council grievance process and the Administrator could not explain how the concerns were being addressed.
Resident Council concerns were not fully documented or brought back to the council for discussion. Residents reported issues with menu options and tough meat, especially roast beef, and asked for the DM to attend meetings, but those concerns were not reflected in the council minutes for multiple months. The AD said she emailed department managers about concerns, but she did not document all concerns or responses in the minutes, and the DON stated the expectation was that concerns and resolutions be recorded and reviewed with the council.
Resident Council concerns were not addressed or tracked in meeting minutes for multiple residents who regularly attended. Residents said the Administrator ran the meetings, concerns were not followed up on, and prior issues never appeared as old business or with documented resolution in later meetings. The AD and Administrator both confirmed the minutes lacked evidence of resident concern resolution.
Failure to Address Resident Council Concerns: A resident council repeatedly raised concerns about cold food, laundry not being returned or put away, plastic ware and paper plates, lack of help with meals, and staff using phones or earbuds during resident care. Meeting minutes over several months did not show that prior concerns were answered or that follow-up was communicated back to the council, and residents stated they felt their concerns were not addressed.
Unresolved Resident Council Dietary Concerns
Penalty
Summary
The facility failed to resolve and communicate its efforts to address repeated dietary concerns raised by residents during Resident Council meetings over multiple months. Resident Council minutes from January through July 2026 documented ongoing complaints that food was the main concern, menus did not reflect resident likes and dislikes, snacks were not being passed, meats were processed, residents were waiting for meals, preferences were not being honored, meals were late, and meal delivery was inconsistent. The minutes also noted that old business was repeatedly carried forward because concerns from prior meetings had not been resolved or followed up by administration. Residents interviewed during the survey reported continued dietary problems, stating that food preferences were not being followed and that menu choices provided to staff did not match what residents received. The Dietary Manager acknowledged awareness of the recurring food concerns and stated she attended Food Committee meetings held after Resident Council, where similar issues were discussed each month. The Activity Director, Social Worker, and Administrator each described a process in which grievances from Resident Council minutes were transferred to grievance forms and reviewed, but the Resident Council continued to report unresolved food issues across several months, including missed dinner trays when a resident was out with family.
Failure to Report Resident Concern to Administration
Penalty
Summary
The facility failed to report a resident concern to administration for investigation for 1 of 3 residents reviewed for dignity and respect. Resident #18 was admitted with diagnoses including mild cognitive impairment of uncertain or unknown etiology, unspecified mood disorder due to known physiological condition, and anxiety disorder, and her MDS assessment indicated she was cognitively intact. Her care plan addressed behaviors including frequent call light use, manipulative behaviors, telling untruths about staff, sexually inappropriate remarks, excessive use of the call bell, becoming obsessed with one staff member, threatening staff, and activating the call bell and then declining assistance. During an interview, Resident #18 stated that a nurse aide would lay on her in bed at night, describing that the aide laid across her stomach with her feet still on the ground on her right side to rest. A nurse aide later stated the resident had told her that another nurse aide had laid on her in bed and that the resident did not like it. The nurse aide said she had been trained to report concerns and grievances to administration, but she did not report this concern or file a grievance because she did not believe the allegation was plausible. The DON and Administrator both stated that a staff member receiving a resident report that another staff member had lain on the resident was required to notify administration.
Resident Council Grievances Not Addressed
Penalty
Summary
The facility failed to implement an effective process to resolve and communicate its efforts to address repeated Resident Council concerns about lack of weekend housekeeping and unlabeled or missing clothing items. Review of Resident Council meeting minutes showed that in May 2026 residents raised concerns about needing more frequent housekeeping visits on the weekend and multiple unlabeled or missing clothing items. In June 2026, the minutes again documented concerns about needing more housekeeping on the weekend for trash removal and multiple unlabeled or missing clothing items, but there was no follow-up noted in the minutes. During the 06/24/2026 Resident Council meeting, residents voiced that their grievances were not being addressed, and the Resident Council President stated housekeeping and laundry had remained a concern for the past two months without resolution. In interviews, the Resident Council President said housekeeping was not seen on weekends and that resident clothing was not being returned when laundry services were provided, with residents obtaining clothes from the donation area. The Activities Director stated she would either ask a staff member to address a grievance immediately or verbally inform the Administrator, DON, or Social Worker, but she did not follow up herself and expected others to inform her of the outcome. The DON stated she was unaware there was a process for grievances related to Resident Council, and the Administrator was unable to explain how Resident Council grievances were being addressed.
Resident Council Concerns Not Documented or Returned to Council
Penalty
Summary
The facility failed to ensure the Resident Council’s concerns were addressed and documented in the Resident Council minutes for 3 of 3 months reviewed, including March, April, and May 2026. During a Resident Council meeting on 6/24/26, residents reported concerns about menu options and the tenderness of the meat served, especially roast beef, stating they had difficulty chewing the meat and had requested other menu items such as chili. They also requested that the dietary manager attend Resident Council meetings so they could speak directly with her, but she had not attended, and residents said they had no way to know whether their concerns had been communicated or what would be done about them. Review of the March, April, and May 2026 Resident Council minutes showed dietary discussions about favorite meals, snacks, grilled lunches, fruits, muffins and moms, taco in a bag, breakfast sandwiches, and fewer carrots, but the minutes did not mention the concerns about tough meat, the menu plan, or the request for the dietary manager to attend. The dietary manager stated she was aware of some concerns through email from the Activity Director and said she addressed what she could, but she had not attended the meeting due to being at the facility only 3 days a week and covering kitchen staffing shortages. The Activity Director stated she emailed department managers when concerns were brought to council and would follow up if no response was received, but she did not get all concerns or responses documented in the minutes. The DON stated it was her expectation that the Activity Director document concerns and resolutions in the Resident Council minutes and bring the information back to the council at the next meeting.
Resident Council Concerns Not Documented or Resolved
Penalty
Summary
The facility failed to consider and timely resolve resident concerns raised in Resident Council meetings, affecting twelve residents who regularly attended. During a Resident Council discussion with three residents, the Administrator was reported to attend and run the meetings, and the residents stated their concerns were not addressed, there was no follow-up, and issues raised in one meeting were never included in subsequent meetings with information on resolution. Review of Resident Council meeting minutes from May 2025 through May 2026 showed no documented old business and no documented evidence of discussion or resolutions to concerns that had been brought up. The Activity Director stated the Administrator ran the meetings and documented the minutes, and confirmed there was no old business documented and no documented resolution of resident concerns. The Administrator also stated he attended the meetings and compiled the minutes, and verified there was no documented evidence of resolutions from resident concerns brought up in the meetings.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to communicate efforts to address and resolve concerns raised during Resident Council meetings over multiple months. Resident Council minutes documented repeated complaints about cold food, laundry not being returned, folded, or put away, the use of plastic silverware and paper plates, residents having to ask for desserts, staff being on cell phones or wearing earbuds during resident care, and residents not receiving help opening food containers or cutting food. In several monthly meetings, the minutes did not show that the facility provided a response to prior concerns or documented any follow-up with the council. The concerns were raised repeatedly from October 2025 through May 2026, including ongoing complaints about cold food and laundry issues, as well as concerns about dining service and staff behavior during care. During the January 2026 meeting, a grievance was filed regarding plastic silverware and paper plates, and later grievances were filed regarding cold food, dessert service, and staff using phones during care. The meeting notes and grievance records showed that the same issues continued to be brought forward by the Resident Council without documented resolution being communicated back to the residents in the council meetings. Resident #75 stated that the Resident Council met monthly, that the Activities Director and Activities Assistants recorded concerns, and that nothing was done about the concerns expressed during the meetings. She said she attended all Resident Council meetings and was frustrated by the lack of follow-up, especially regarding laundry and cold food. During the Resident Council interview, residents stated their concerns were not addressed and that they were told the issues were being reviewed, but nothing was ever done, making them feel like they did not make any difference.
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