Failure to Address Resident Grievances and Excessive Call Light Wait Times
Summary
The facility failed to adequately address resident grievances regarding excessive call light wait times for all 18 residents reviewed. Multiple residents reported waiting extended periods, ranging from 15 minutes to over two hours, for assistance after activating their call lights. Several residents described being left in soiled conditions, experiencing humiliation, discomfort, and emotional distress as a result. Interviews revealed that staff sometimes turned off call lights without providing the requested assistance, and residents felt their complaints were either ignored or not resolved. The facility's call light system was operational, but there were no visual indicators outside resident rooms or at the nurse's station, relying solely on a beeper system for staff notification. The DON and ADON confirmed that call light audits and monitoring, which had been implemented after a previous survey, were discontinued after a certain date with no explanation or documentation for the cessation. There was no specific facility policy or defined expectation for timely call light response, and staff education did not specifically address prompt call light answering. The ADON was unable to articulate a standard for reasonable response time, and the facility's in-service records did not include targeted training on this issue. Review of resident care plans and grievance records showed that many residents required substantial to maximal assistance with ADLs and were frequently incontinent, making timely response to call lights critical for their dignity and hygiene. Grievance forms documented repeated complaints about long wait times, with some forms lacking evidence of resolution or follow-up. In several cases, residents or their families reported that grievances were not addressed, and staff actions were limited to verbal reassurances or corrective actions without systemic improvement. The facility's policy on resident rights emphasized dignity and prompt grievance resolution, but the documented practices did not align with these standards.
Penalty
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Over more than a year, residents repeatedly reported during Resident Council meetings that call lights were not answered timely, staff sometimes turned off call lights without meeting needs, ice and water were not passed consistently on all shifts, water pitchers were not washed as expected, and care was not always provided during meal times. Residents also described staff using poor attitudes, including cursing and aggressive tones, and noted that coffee on hall carts was often empty or cold at breakfast. Despite these concerns being raised month after month, residents stated they felt the facility only responded by saying staff were being educated, while the same problems continued. The Social Worker and DON acknowledged that these issues had been discussed numerous times without true resolution, and residents expressed a desire for their needs to be met and for clear feedback from administration about efforts to address their ongoing concerns.
A facility failed to provide private space for resident council meetings, which were held in the dining room for 15 of 15 confidential residents reviewed. During a meeting with 12 residents, staff entered the room despite do-not-enter signs posted on both doors, and residents said interruptions were frequent and made them feel unable to speak freely. The Activity Director and Administrator both stated the meetings were expected to remain private, and the facility policy stated the resident council would be provided private space.
The facility failed to effectively address and communicate follow-up on concerns raised in Resident Council meetings, leading several residents to stop attending because they felt nothing changed. Over several months, residents reported issues including nighttime noise, aides not staying on task, delays in getting out of bed for activities, inadequate bathroom and room cleaning, running out of ordered food, poor food flavor and temperature, and staff cell phone use during work time causing slow call light response. Meeting minutes showed no documented follow-up to these concerns, and residents reported no observable improvements. The Administrator acknowledged there was no standard process for handling Resident Council issues and that any actions taken were not formally communicated back to residents.
Failure to Respond to Resident Council Grievances: The facility did not provide verbal or written responses to Resident Council grievances about nursing, dietary, housekeeping, and daily living concerns. The council reported issues such as unchanging bed linens, noisy and disrespectful housekeeping, loud staff conversations, meal and tray concerns, labeling personal items, and resident care concerns, but the facility did not consistently document a representative response or rationale.
Resident Council concerns were not addressed or communicated in a timely manner. Residents reported repeated issues with staff shutting off call lights before needs were met, not following the smoking plan, and meal trays being passed late, resulting in cold food. These concerns were raised in multiple council meetings over several months, but no timely resolution or update was shown.
Over an extended period, Resident Council meeting minutes repeatedly documented residents’ concerns that call lights were not being answered in a timely manner, despite notes that nursing administration would address the issue. A resident council leader later reported call light wait times of 30–60 minutes, especially when agency staff worked second and night shifts, and stated that staff often said they would return but did not do so promptly. Residents also lacked information on where state agency reports and Ombudsman information were kept, and reported that staff addressed them with terms like “Momma” and “Grandma” instead of using their names, contrary to expectations confirmed by facility staff. The facility’s grievance policy requires prompt resolution of grievances and written responses with rationale, but the same concerns continued to recur in council minutes.
Ongoing Failure to Resolve Resident Council Concerns About Call Lights and Basic Services
Penalty
Summary
The deficiency involves the facility’s failure over a 13‑month period to effectively resolve and communicate resolution of repeated concerns raised in Resident Council meetings, particularly regarding call light response times, staff turning off call lights without meeting needs, inconsistent ice and water pass, and care during meal times. Resident Council minutes from multiple months document that residents, especially those on the 200 hall, repeatedly reported that call lights were not answered in a timely manner and that staff sometimes turned off call lights and left without providing the requested care. Residents also reported that when they turned their call lights back on, staff questioned why they had done so, despite their needs not having been met. These concerns were documented as new issues in successive meetings, indicating that the same problems persisted over time. The Resident Council minutes further show that residents repeatedly complained that ice was not being passed consistently on second and third shifts and on all halls, and that water pitchers were not being washed weekly as expected. At various meetings, residents stated that ice was not being passed daily on all shifts, that ice was not being passed routinely, and that ice was not being passed on every shift. Additional concerns were raised about staff attitudes, including cursing and using an aggressive tone of voice, and about care not being provided during meal times. Residents also reported that coffee on the hall cart was often empty or cold at breakfast. These issues were brought up under both Old Business and New Business in multiple meetings, demonstrating that residents perceived them as ongoing, unresolved problems. During a Resident Council group interview, several residents who lived on the 200 hall and regularly attended the meetings stated they felt the facility did not truly address their concerns because the typical response they heard was that staff were being educated, yet the same problems continued. Multiple residents agreed that call lights not being answered timely was a continual problem and expressed that they wanted resolution and their needs to be met, as well as feedback from administration about efforts made to address their concerns. The Social Worker confirmed that call light response time, passing ice on all shifts, and providing care during meal times had been discussed numerous times and acknowledged there was still no resolution to these issues. The DON acknowledged that grievances from Resident Council regarding clinical issues were assigned to her and that the 200 hall was considered challenging, with residents there being more alert, oriented, and vocal about their needs, but the ongoing nature of the same complaints showed that the facility did not effectively resolve or communicate resolution of the residents’ repeated concerns. The Administrator, who had recently started in the role, stated that they were hoping to achieve resolution of the call light response concerns and that call lights should be answered as quickly as possible, with staff not turning off call lights and failing to return to meet residents’ needs. Despite these stated expectations, the documented Resident Council minutes and resident interviews demonstrate that residents continued to experience and report the same issues over many months. Overall, the deficiency centers on the facility’s inaction and ineffective response to recurring Resident Council complaints, resulting in residents feeling that their concerns about call light response, ice and water service, staff behavior, and care during meals were not being resolved or adequately addressed.
Resident Council Meetings Lacked Privacy
Penalty
Summary
The facility failed to provide a private meeting space for resident council meetings for 15 of 15 confidential residents reviewed for resident council. Observation and interview on 04/29/26 at 9:30 AM during a confidential resident group meeting with 12 residents revealed that the resident council meetings were held once a month in the dining room. The dining room had two entrances, both doors were closed, and the Activity Director posted do not enter signs on each door, but three staff members still entered the dining room during the meeting. Residents stated that interruptions during resident council meetings were frequent and that they felt like they could not speak freely because of staff interruptions. On 04/30/26 at 6:25 PM, the Activity Director stated staff interrupted the meetings by entering or attempting to enter the dining room and that she would ask staff to leave. On 05/01/26 at 8:22 AM, the Administrator stated staff were expected to respect residents' privacy during resident council meetings so residents could express concerns without feeling intimidated. The facility policy titled Resident Council, revised 12/2016, stated that the facility would provide the resident council with private space.
Failure to Address and Communicate Follow-Up on Resident Council Concerns
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to respond to and follow up on concerns raised during Resident Council meetings, affecting multiple residents who attended these meetings and potentially all residents in the facility. Review of Resident Council minutes for three consecutive months showed residents repeatedly voiced concerns about noise at night, aides on night shift not staying on task, delays in being assisted out of bed in time for activities, bathrooms not being cleaned properly, running out of ordered food, and rooms not being cleaned on weekends. The minutes did not document any follow-up actions or responses to these concerns. Residents reported that Resident Council meetings had become poorly attended because residents felt that nothing changed when they brought up issues. Interviews with the Resident Council President and other residents confirmed that specific concerns, such as poor food flavor and temperature and staff cell phone use during work time leading to slow call light response and delayed tasks, had been raised in Resident Council but had not resulted in noticeable changes. One resident recounted that a former cook had attended a meeting, listened to food-related complaints, and stated he would make menu and preparation changes, but residents perceived no improvement in food quality afterward. Another resident confirmed that concerns about staff cell phone use had been discussed, but she was unaware of any action taken. The Administrator acknowledged there was no standard method for addressing Resident Council concerns and confirmed that, although concerns were addressed after minutes were completed, communication about any actions taken did not get back to the residents.
Failure to Respond to Resident Council Grievances
Penalty
Summary
The facility failed to honor residents’ right to organize and participate in resident/family groups by not providing a verbal or written response to the Resident Council regarding grievances raised in multiple meetings. The report states that the facility did not consider the views of the resident group or act promptly upon grievances and recommendations concerning resident care and life in the facility, and did not demonstrate its response and rationale for its response for 12 of 15 confidential residents reviewed for meeting grievances. Record review showed the Resident Council submitted grievances related to nursing services, dietary services, housekeeping services, and other daily living concerns across several months. These included reports that bed sheets were not being changed for a month or more, housekeepers were noisy and disrespectful in the mornings, exterminator visits were requested more often, a shower room heater needed repair before winter, staff talked too loudly in the hallway, residents wanted boiled eggs instead of powdered eggs, more outside activities were requested, beds should be made daily with fresh sheets, nursing staff made negative remarks about other staff members, carts were being banged into walls, medication drawers were being slammed, laundry staff should label personal items, toast was not being served because bread was too soft or too hard, meal trays were left in the hallway overnight, a night nurse aide spent too much time with one resident and was loud, and nurse aides were not paying attention during shower chair transfers.
Resident Council Concerns Not Addressed or Communicated Timely
Penalty
Summary
The facility failed to ensure residents were updated in a timely manner regarding Resident Council concerns and failed to correct those concerns for a period of four months. Facility policy stated that the Resident Council is intended to provide residents, families, and resident representatives a forum to discuss concerns and suggestions for improvement, and that a Resident Council Response Form would be used to track issues and their resolution. The policy also stated that the department related to any issue would be responsible for addressing the concern, with QAPI review as applicable. Review of Resident Council minutes from February 2026 through April 2026 showed a pattern of concerns involving staff shutting call lights off without meeting residents' needs, failure to follow the facility smoking plan to assist residents who wanted to smoke, and dietary trays not being passed by nursing staff in a timely manner, resulting in cold food for residents. During a Resident Council meeting, interviews with residents who regularly attended the meetings indicated these concerns had been raised in several prior monthly meetings with no resolution. The residents stated that waiting until the next monthly Resident Council meeting was not a timely response to learn of facility resolutions, and no evidence was provided showing timely corrective actions or timely updates to residents regarding those concerns.
Ongoing Unresolved Resident Council Concerns About Call Light Response and Communication
Penalty
Summary
The deficiency involves the facility’s failure to resolve recurring resident council concerns about delayed call light response times and related communication issues. Review of Resident Council minutes from January 2025 through February 2026 showed that, in multiple monthly meetings with between 14 and 20 residents present, residents repeatedly reported that call lights were not being answered in a timely manner. Each set of minutes documented that the issue would be addressed by nursing administration, but the same concern continued to appear over many months. The facility’s grievance/complaint policy, dated April 2017, states that the administrator and staff will make prompt efforts to resolve grievances to the satisfaction of the resident or representative, and that all grievances or recommendations from resident or family groups concerning resident care will be considered and responded to in writing, including a rationale for the response. During an interview on April 22, 2026, the Resident Council President reported ongoing concerns with call lights, stating that staff would answer the call light and say they would return shortly, but often did not return promptly, with wait times reported between 30 minutes to an hour. The Resident Council President also reported that longer wait times occurred when agency staff were on duty, particularly on second and night shifts, and confirmed that the Resident Council did not have information on where state agency reports and Ombudsman information were kept. The Resident Council President further stated that staff should address residents by name rather than using terms such as “Momma” and “Grandma.” Activity staff confirmed that council concerns were reported to department directors and verified the lack of documentation informing the Resident Council where to locate state agency reports and Ombudsman information. An administrative nurse confirmed being invited to a Resident Council meeting to address call light response and verified that staff should address residents by name rather than with informal familial terms.
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