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.
Resident Council Grievances Not Documented or Addressed: The facility failed to consider resident council concerns or show responses to grievances for 10 of 10 council members reviewed. All 10 residents stated they did not feel their views were taken into account or that complaints were followed up, and the ADMN reported there was no grievance documentation available for several months and no resident council meetings since she began in the role.
Resident Council Meeting Held Without Privacy: The facility failed to provide a private space for a monthly resident council meeting, instead holding it in an open activity area in the hallway near the Business Office, MDS Office, and Therapy Gym. Staff and volunteers walked through during the meeting, no privacy signs were posted, and the Activity Director acknowledged the meeting was not held in a private setting even though the facility's policy states the resident council group is provided with space and privacy for meetings.
Resident council meetings were held in the main dining room instead of a private space. The Activity Director said the activity office was too small for all attendees, and observations showed the room had no doors, staff walked through during the meeting, and kitchen noise could be heard, preventing confidential discussion of concerns. The Assistant Activity Director said the council had met there about three times with about 26 members present, and the ADMIN noted other private locations were available, such as the private dining room.
Resident Council grievances and recommendations were not consistently addressed or documented by facility leadership. Residents raised repeated concerns about food quality and temperature, housekeeping, staffing, activities, and staff interactions, but grievance records showed no grievances were created for the issues discussed in council minutes. Interviews with the SW, AD, and ADM showed unclear responsibility for follow-up and no clear process for sharing responses back to the council, despite facility policy requiring administrator review and responses to be presented at the next meeting.
Resident council grievances were not fully followed up on or resolved, including repeated complaints about late meals, coffee timing, food quality, dirty utensils, missing items, and cold dinners. Residents reported ongoing dietary problems after staff turnover, while staff interviews showed unclear responsibility for grievance follow-up and inconsistent resolution of group concerns. Facility policy required the community to consider resident and family group views and communicate decisions regarding their proposals.
Resident council meetings were held in the dining room and were repeatedly interrupted by staff entering and exiting the area, despite the meetings being intended as confidential. The ombudsman observed multiple staff disruptions, and residents stated this was typical. Staff and administration acknowledged the meetings were meant to be private, but there were no signs posted and staff were not clearly aware of the confidentiality expectation.
Resident council meetings were held in the activity room without privacy, and staff and a physician entered during a meeting to see two residents. Eight alert and oriented residents said staff came in and out, they filtered what they said because staff were present, and interruptions occurred despite a sign posted that a meeting was in progress. The Activities Director and Administrator said staff or visitors should only attend if invited, while an LVN said she and the doctor entered because he needed to see two residents.
Resident council meetings were not consistently held as private resident-only meetings. Residents reported that meetings were conducted as town hall meetings with staff present, and one resident said the first meeting was held in a hallway with staff nearby. The Ombudsman said the facility had not had a Resident Council meeting in 2 years, while the ADM, AD, ADON, DON, and CNA staff gave conflicting accounts about staff participation, hallway traffic, and who was responsible for organizing the meetings. The facility policy stated resident council is a formal resident group open to all residents and may include an activity director as a liaison if approved by the group.
Resident council grievances were not promptly resolved, and 15 anonymous residents said their concerns were not being considered or given any resolution. Minutes showed repeated complaints about shortages of drinks and food items, repetitive menus, the meal of the month not returning, and the Activity Director being pulled to the floor instead of helping with activities. The Activity Director said she was assigned as a nurse aide on multiple halls, and the Administrator said she reviewed the minutes but did not attend resident council meetings to provide resolutions.
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