§483.10(f)(5) The resident has a right to organize and participate in resident groups in the facility.
(i) The facility must provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner.
(ii) Staff, visitors, or other guests may attend resident group or family group meetings only at the respective group's invitation.
(iii) The facility must provide a designated staff person who is approved by the resident or family group and the facility and who is responsible for providing assistance and responding to written requests that result from group meetings.
(iv) The facility must consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility.
(A) The facility must be able to demonstrate their response and rationale for such response.
(B) This should not be construed to mean that the facility must implement as recommended every request of the resident or family group.
§483.10(f)(6) The resident has a right to participate in family groups.
§483.10(f)(7) The resident has a right to have family member(s) or other resident representative(s) meet in the facility with the families or resident representative(s) of other residents in the facility.
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Observations:
Based on review of facility policy, facility documents, and resident and staff interviews, it was determined that the facility failed to correct Resident Council concerns for a period of three months (April 2026 through June 2026).
Findings:
Review of facility policy, "Resident Council," dated 11/18/25, indicated "Staff is to follow up with any of the residents' concerns that were voiced at the meeting so they can be addressed at the next meeting."
Review of facility policy, "Dining Room," dated 11/18/25, indicated, " To promote a home-like environment and enhance socialization." The policy also indicated that the dining room would be open seven days a week and that Restorative Aides would assist during the lunch meal and during the evening meal and on weekends, residents would be assisted by staff from the Nursing wings.
Review of the Resident Council minutes over the past three months, April 2026 through June 2026, revealed a pattern/trend with issues regarding residents not being able to go to the dining room for the supper / evening meal and issues with meal trays being served cold due to sitting in the hallway for a period of time after the tray carts are delivered to the nursing units.
Interviews with Residents R1, R2, R3, R4, R5, R6, R7, R8, and R9 indicated that the dining room is closed for the supper meal at least weekly and sometimes more. The interviews also indicated that the room trays sit in the hallway for a period of time before they are delivered to the residents and they are cold when they receive them.
Interviews with nursing staff all indicated that the Nursing Supervisor determines if the dining room will be closed for supper by 3:30 p.m. on the day of closing.
Information provided by the facility revealed that the dining room was closed for supper on the following dates in June and July, 6/6/26, 6/7/26, 6/18/26, 6/20/26, 6/21/26, 6/22/26, 6/23/26, 6/25/26, 6/26/26, 6/29/26, 6/30/26, 7/4/26, 7/7/26, 7/9/26, 7/11/26, 7/12/26 and 7/13/26.
An interview with the Nursing Home Administrator on 7/17/26, at approximately 2:35 p.m. confirmed that the facility had not corrected the Resident Council concerns regarding the dining room being closed for the supper meals and residents receiving cold trays from them sitting in the hallways for a period of time before receiving them April 2026, May 2026, and June 2026 Resident Council meetings.
No evidence was provided to ensure that there was timely corrective actions regarding the residents' concerns that were verbalized and also stated in the Resident Council minutes for the past three months reviewed.
28 Pa. Code 201.14 (a) Responsibility of licensee
28 Pa. Code 201.18 (e)(1)(4) Management
28 Pa. Code 201.29(a) Resident rights
| | Plan of Correction - To be completed: 09/15/2026
1. During the Resident Council meeting held on July 28, 2026, concerns regarding dining room availability and food temperatures were reviewed. Residents reported that food temperatures have improved. Residents were informed that the facility is committed to maintaining dining room service during all scheduled meal periods unless an emergency exists that would compromise resident safety. The process for requesting approval to cancel dining room services was reviewed, and residents were reassured that cancellation of dining room service should occur only in rare emergency situations. Residents expressed satisfaction that the dining room has remained consistently open during evenings and weekends.
Effective immediately, the facility has implemented a new Resident Council Concern Resolution Process. All concerns voiced during Resident Council meetings will be documented on a Resident Council Concern Log that will be reviewed after the meeting by the Nursing Home Administrator, Director of Nursing, and Activity Director. Each concern will be assigned to the appropriate department manager with a required due date for follow-up. The Nursing Home Administrator or designee will review the log to ensure concerns are addressed timely. The status and resolution of each concern will be communicated back to Resident Council at the next scheduled meeting or sooner, when appropriate, to ensure residents receive timely feedback regarding actions taken.
2. All Registered Nurse Supervisors were educated regarding the dining room policy and the expectation that dining room services will not be canceled unless an emergency exists that compromises resident safety. The Nursing Home Administrator and/or Director of Nursing must be notified and approve any cancellation of dining room services before implementation.
All Registered Nurse Supervisors will also be educated on assisting with meal tray distribution upon arrival to the nursing units to promote timely meal delivery and maintain safe food temperatures.
Department Managers will be educated on the new Resident Council Concern Resolution Process, including documentation requirements, assigned responsibilities, expected timeframes for resolution, and communication back to residents regarding completed corrective actions.
3. Nursing, Activities, Restorative Nursing, Hospitality Aides, and Dietary staff will receive education regarding the importance of dining room participation as a resident-centered practice. Education will include resident rights related to dignity, choice, socialization, and maintaining dining room services except in emergency situations affecting resident safety.
Additional education will be provided to all staff on the importance of timely meal tray delivery to maintain safe food temperatures.
Education will also be provided to Department Managers, Resident Council facilitators, and facility leadership regarding the new process for documenting, assigning, tracking, and resolving Resident Council concerns to ensure concerns are addressed promptly, accountability is maintained, and resolutions are communicated back to residents.
4. The Nursing Home Administrator or designee will complete weekly audits of dining room operations for four weeks, followed by monthly audits for three months, to verify compliance. Audits will include review of dining room availability during scheduled meal periods, reasons for any dining room interruptions, resident satisfaction, and meal service observations. Any identified concerns will result in additional education, corrective action, and/or process improvement.
The Dietary Director or designee will complete weekly audits of tray temperatures on the last tray delivered to each nursing unit. On weekends, designated nursing staff will obtain and document tray temperatures according to a rotating unit schedule to ensure all resident care areas are monitored consistently. Audit findings will be reviewed for trends and addressed through education, corrective action, and/or process improvement as indicated.
The Nursing Home Administrator or designee will audit the Resident Council Concern Log monthly to ensure all concerns have been assigned, addressed within established timeframes, and communicated back to residents. Any overdue or unresolved concerns will be immediately reviewed with the responsible Department Manager and corrective action implemented as needed.
Audit results will be reviewed at the Quarterly Quality Assurance and Performance Improvement (QAPI) Committee meetings. The QAPI Committee will monitor compliance, identify trends, evaluate the effectiveness of corrective actions, and implement additional process improvements as necessary to ensure sustained compliance.
5. The corrective action completion date will be September 15, 2026.
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