Failure to Follow Up on Resident Council Grievances
Summary
The facility failed to provide residents with a response, action, and rationale for grievances raised in resident/family group meetings. The grievance and concern policy stated residents have the right to receive a written decision on a grievance, and that within three days of receiving a grievance the grievance coordinator was to provide an explanation of the finding and proposed remedies to the complainant and aggrieved party. However, residents who regularly attended the resident council and food council meetings reported that concerns brought up in those meetings were not followed up on and continued to recur month after month. During interviews, residents said concerns about staff using ordering tablets incorrectly, lack of healthy snack choices, refusal of fresh fruit, and not receiving soup varieties or homemade soup were repeatedly raised without clear resolution. Record review showed food council minutes documenting concerns about staff communication, fresh fruit, homemade soups, cold room trays, inconsistent room tray delivery times, missing room tray meals, and low sodium soup options. The grievance materials provided by the facility referenced that some concerns had been addressed in meeting minutes, but the record did not show follow-up with the individual residents or the food council as a group regarding what had been done to resolve the concerns after the meetings. Staff interviews confirmed that concerns raised in the food council meetings were not consistently written up as formal grievances and that residents were not brought back a resolution.
Penalty
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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.
The facility failed to adequately address repeated resident council concerns about limited snack variety and consistently cold food. Over many months, residents with various medical conditions, including dementia, CKD, pulmonary disease, and dysphagia, repeatedly reported that snacks lacked variety and that meals were often served cold in both rooms and the dining area. Concern forms generated from council meetings were incomplete or failed to address all issues raised, and residents stated they were not offered additional snack options or information on available items. The Activity Director confirmed that these concerns were ongoing and frequently reported, while also acknowledging a lack of knowledge about any effective actions taken to resolve the problems, despite a policy requiring written administrative responses to council concerns.
The facility failed to investigate or respond to repeated food-related complaints raised through resident Food Committee meetings, including concerns about food quality, temperature, portion sizes, presentation, menu variety, use of Styrofoam, lack of fresh bread, unannounced substitutions, and inconsistent snack service. Meeting minutes over several months documented ongoing dissatisfaction, yet there was no evidence of a plan of action, follow-up, or feedback to residents. The Dietary Manager and Administrator acknowledged awareness of complaints and confirmed there was no tracking system for resolution, while the Ombudsman reported multiple unresolved food complaints. Several residents reported being served burnt or tough food, unwanted substitutions, cold meals, plastic silverware, and repetitive menus, and stated that despite voicing concerns in resident groups, nothing changed.
Nine residents raised concerns about delayed medication administration, staffing, and continuity of care during a council meeting. The facility did not document specific details of these concerns or provide evidence of follow-up or action taken in response, and repeated requests for such documentation from the administrator were not answered.
The facility did not resolve repeated resident council complaints about cracks and holes in the driveway, resulting in incidents where residents in wheelchairs became stuck. Despite ongoing reports to administration and staff, concerns were not addressed in a timely manner, and residents felt their issues were ignored.
The facility did not respond to concerns raised by residents during council meetings, including issues with dietary services, late medication administration on weekends, improper medication handling, and ill-fitting bed sheets. Two residents reported that their concerns were repeatedly brought up without action, and the administrator confirmed a lack of evidence showing staff response.
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 Address Repeated Resident Council Concerns About Snacks and Food Temperature
Penalty
Summary
The deficiency involves the facility’s failure to adequately address and respond to recurring concerns raised in resident council meetings regarding snack variety and food temperatures, affecting four cognitively intact or impaired residents with multiple medical conditions, including atrial fibrillation, pulmonary disease, dementia, chronic kidney disease, vascular disease, and dysphagia. Resident council minutes over approximately a one‑year period documented repeated complaints about limited snack options and cold food at meals. Despite these concerns being voiced at multiple meetings, the corresponding concern forms were incomplete or failed to address all issues raised. For example, some forms did not mention food temperature concerns at all, others only partially addressed snack variety, and some did not address either the lack of snack variety or cold food. Residents reported that they had asked for more variety in chips and fruit and had not been offered choices or a list of items available from the supplier, and they stated that the facility gave excuses for the continued reliance on peanut butter sandwiches. Residents also reported that food was consistently served cold both in their rooms and in the dining room. The Activity Director confirmed that resident concerns were documented in council minutes and that concern forms were written and given to department heads, but acknowledged that residents had consistent, repeated concerns about snack variety and cold food over the majority of the months reviewed. The Activity Director denied knowledge that the requested variety of snacks was ever offered, denied knowledge of what the facility was doing to improve food temperatures, and was unaware of any test trays being completed or results shared with residents. The facility’s own policy stated that administration shall respond in writing to concerns and recommendations raised by the resident council, yet the repeated, unresolved complaints and incomplete concern forms demonstrated that resident council concerns were not consistently or effectively addressed.
Failure to Address Repeated Food Committee Complaints and Resident Group Concerns
Penalty
Summary
The deficiency involves the facility’s failure to honor residents’ rights to organize and participate in resident/family groups by not investigating, addressing, or implementing corrective actions for repeated food service complaints raised through the Food Committee. Review of Food Committee minutes from November 2025 through January 2026 showed multiple ongoing complaints about food quality, temperature, portion sizes, presentation, menu variety, use of Styrofoam, lack of fresh bread, dislike of certain foods, inconsistent snack pass, and lack of coffee availability. Meeting minutes from several dates documented concerns about meals being served cold, limited alternatives for resident preferences, repetitive menus, and dissatisfaction with the amount and type of pasta served, as well as food being overcooked or undercooked. Despite these recurring issues, there was no documented plan of action, investigation, follow-up, or feedback to residents in the Food Committee records. Interviews further confirmed the lack of response to resident group concerns. The Dietary Manager acknowledged awareness of some complaints but could not provide documentation of investigations, changes to food service practices, or communication back to residents. The Ombudsman reported multiple food complaints from several residents, including burnt lasagna, lack of fresh bread, unannounced food substitutions, and use of Styrofoam plateware, and stated she had exhausted all avenues with management. The Administrator confirmed there was no tracking system to ensure food-related complaints raised through the Food Council were followed up and resolved. Individual residents reported being served burnt lasagna with an unrequested substitution of mashed potatoes and gravy, food sometimes being cold, lack of fresh bread, dissatisfaction with plastic silverware, tough food that was difficult to cut, too many sandwiches, and a snack cart that was inconsistently passed with no variety. Residents stated they attended Resident Council and Food Committee meetings to voice concerns but saw no changes, affecting 15 identified residents and potentially all residents receiving food from the kitchen.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to promptly address grievances related to resident care that were raised during a resident council meeting attended by nine residents. Concerns were voiced regarding untimely medication administration, staffing, and continuity of care. The meeting minutes referenced additional details on the back of the form, but no further information was provided, and there was no documentation specifying the exact nature of the concerns about staffing and continuity of care. There was also no evidence that the facility followed up to clarify or address these concerns, nor was there any documentation of actions taken in response. Requests for evidence of follow-up or action from the facility administrator on three separate occasions went unanswered.
Failure to Address Resident Council Concerns About Unsafe Driveway
Penalty
Summary
The facility failed to address and resolve concerns raised by the resident council regarding the condition of the facility driveway, which was repeatedly reported as having cracks and holes. Resident council meeting minutes documented ongoing complaints over several months about the driveway's poor condition, including specific incidents where residents in wheelchairs became stuck in the cracks. Residents expressed frustration that their concerns were not being addressed or resolved by administration, despite being reported multiple times. Interviews with residents and staff confirmed that complaints submitted to the administration were not answered in a timely manner, if at all. The Activity Director, who facilitated the council meetings, stated that she relayed concerns to the Administrator but acknowledged that responses were lacking. The facility's policy indicated that resident council feedback should be reviewed by the QAPI committee, but there was no evidence that the concerns about the driveway were resolved or appropriately addressed.
Failure to Address Resident Council Concerns
Penalty
Summary
The facility failed to respond to concerns raised by residents during Resident Council meetings, as evidenced by a review of meeting minutes and staff interviews. Specific issues documented included complaints about the dietary department, late administration of medications on weekends due to nurses assisting aides, nurses leaving medications at the bedside, and sheets not fitting larger beds. Despite these concerns being recorded in the Resident Council Meeting Minutes, there was no evidence that the facility took action to address them, except for a note that more blue sheets for larger beds were provided on one occasion. Interviews with two residents who regularly attended the meetings confirmed that multiple concerns had been brought up each month without any resulting action. The facility administrator also verified the absence of documentation or evidence showing that staff had responded to the issues raised during the meetings. This deficiency was identified during an investigation under a specific complaint number and affected at least two residents out of the four reviewed for Resident Council participation.
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