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
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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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