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.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
The facility failed to respond in a timely and effective manner to repeated concerns raised through the resident council regarding long call light response times, missed or unscheduled showers, and perceived understaffing. Over multiple months, council minutes documented the same unresolved issues, with only a general note that past complaints and corrective actions were reviewed and an explanation that each aide was responsible for many residents, but without clear documentation of actions taken. During a group interview, residents reported that their complaints were recorded but that they were not informed of any resolutions. The NHA, DON, and Regional DON acknowledged that the facility did not adequately respond to these resident council concerns, constituting a failure to honor residents' rights to meaningful participation in resident/family groups.
The facility failed over several months to respond to repeated resident council concerns about inadequate staff response to care needs, including delayed call light response, lack of licensed nurse involvement, insufficient staffing on units when CNAs took breaks together, late meals, and residents not being assisted to or from bed or the dining room in a timely manner. Residents reported being neglected or left unattended while staff used cell phones or earbuds for personal activities, with some residents left in soiled briefs, not fed, or waiting hours for transfers. A group of residents documented these issues in a signed letter, and during a group interview most residents stated that administration had not resolved these concerns. Facility documentation of its response did not demonstrate that staff were educated or instructed to correct the timeliness of care or the length of staff breaks, and the administrator acknowledged the failure to respond promptly to the resident council’s grievances.
The facility failed to act promptly on repeated Resident Council concerns about confused, wandering residents entering other residents' rooms and disturbing them. Over several months, council minutes documented reports of residents entering rooms late at night, removing items, and roaming halls after being moved from a dementia unit, without documented resolution or follow-up. Individual and group interviews revealed that residents continued to experience confused residents entering their rooms daily, taking food and personal items, and in one case grabbing and pushing a resident's wheelchair, while staff response was described as minimal and largely limited to verbal redirection. Residents also reported suggesting the use of stop signs across doorways during council meetings but stated they had not received the signs or any response to this request.
Surveyors found that the facility did not respond to grievances raised by a resident group regarding inadequate chairs for visitors and missing laundry. The facility’s grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet resident council minutes showed that concerns about insufficient visitor seating and missing laundry had been reported previously, and residents again reported the same issues during a confidential group interview. There was no evidence that the facility had taken action to address these ongoing concerns, resulting in a deficiency related to resident/family group rights and facility response.
Over a three-month period, the facility did not act on or document follow-up to concerns repeatedly raised in Resident Council meetings. Residents reported systemic issues with call bells not being answered timely, agency staff turning off call bells without providing assistance, poor care on weekends, and medications not being delivered on time. Although facility policy requires that all Resident Council feedback be addressed in writing, the follow-up sections of the council minutes for each month were left blank, and the NHA confirmed that residents' views and concerns about care and daily life were not promptly considered or addressed.
Multiple cognitively intact residents reported ongoing delays in call bell response times, with waits exceeding 30 minutes and sometimes up to two hours. Despite documented grievances and interviews, the facility did not demonstrate effective resolution or follow-up regarding these complaints, impacting residents' timely access to assistance.
For three consecutive months, residents unanimously reported during council meetings that staff failed to leave call bells within reach on all units and shifts. A resident also reported being left unattended in a wheelchair without access to a call bell, and the DON confirmed the facility did not effectively address these concerns.
Multiple residents repeatedly reported long wait times for care and delayed meal distribution, with meal trays left sitting and food becoming cold. Despite these ongoing concerns being raised in Resident Council meetings, the facility failed to file or document grievances as required and did not keep residents informed of any actions taken, leaving the issues unresolved.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Get More From Your Search Results
Create an account to access advanced search filters, save your searches, and get unlimited access to detailed Plan of Corrections.
Create an Account