A facility failed to initiate a grievance for concerns raised during a resident council meeting. Residents reported that concerns were not consistently resolved, including getting residents out of bed for meals and activities and shortages of washcloths and towels. Review of grievance logs showed no matching grievances, and the Activities Director stated a grievance should have been initiated.
Resident Council concerns were repeatedly raised but not documented as grievances or shown to have been addressed, and no follow-up responses or rationale were provided back to residents. Meeting minutes reflected ongoing complaints about locked doors, cold food, delayed call lights, staff sleeping or socializing, noise at night, laundry issues, missing belongings, and other resident care and quality-of-life concerns, while the Grievance Log showed no Resident Council concerns were logged.
Resident Council concerns were not followed up or documented in the grievance process, leaving issues unresolved and the Council ineffective. Residents reported loud hallway საუბars by staff at night, laundry being returned to the wrong rooms, and a Hoyer lift battery failure that left residents suspended during transfers; staff and the Administrator confirmed these concerns were not logged or resolved in the formal grievance system, and meeting minutes showed no documented follow-up.
Resident Council concerns were not properly acted on, documented, or resolved. Meeting minutes showed repeated complaints about late meal trays, shower frequency, tough meats, missing condiments, and food requests not being followed, but the grievance log had no entries for these issues and no grievance forms were completed. The Activity Director stated grievances were not done for Resident Council as a whole, and residents reported the concerns had not improved.
Failure to respond to Resident Council concerns left multiple issues unresolved and made the council process ineffective. Resident Council minutes documented ongoing complaints about call light wait times, care delivery, meal service, TV problems, smoking, language barriers, and other resident concerns, but the follow-up sections were blank and the grievance log showed no resolution for those issues. Interviews confirmed concerns were discussed with the AD and Administrator, but documentation and resolution were inconsistent.
Resident Council concerns were not accurately documented or addressed in meeting minutes over several months. Minutes often stated no issues or concerns were raised, even though residents reported grievances about staff behavior, call light response, meals, maintenance, and other facility issues. The AD acknowledged concerns were escalated to grievance forms but still documented no concerns on the council minutes, and the DON stated this was not accurate.
Resident Council grievances were not timely addressed and verbal concerns were not consistently identified or documented. Residents reported repeated food concerns, including frequent cooked carrots and a resident’s preference to avoid tomato-based foods due to RA and nightshade sensitivity, but no resolution was communicated. Staff said concerns were only submitted as grievances after being repeated, and the resident’s no-tomato preference was not added to the food profile.
Resident Council concerns were not handled timely, verbal grievances were not identified or logged, residents were not routinely informed about rights, and anonymous grievance access was not available. Residents reported being unclear on how to file a grievance, did not know where Ombuds info was posted, and staff said grievance forms were kept at the nurse station with no anonymous drop box.
Resident Council grievances were not reviewed or documented. Residents raised concerns about shower schedules, ice water, linens, call light delays, staff name tags, trash removal, and bathroom cleanliness, but meeting minutes did not show review of resident rights or the grievance policy, and no grievance forms or written responses were completed. RC members said they were unaware of their right to a written response, while the Activities Director stated concerns were only discussed with the Administrator after meetings.
Resident council concerns were not communicated back to members, and meeting minutes for multiple months showed blank old business and new business sections. The Activities Director said she did not document follow-up on prior concerns and only asked if the council still had the same concerns, while the Administrator confirmed the council was not informed of grievance results.
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