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F0565
E

Failure to Address and Resolve Resident Grievances Regarding Call Light Response and Water Pass

Portage, Michigan Survey Completed on 04-09-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that grievances raised by residents during Resident Council (RC) meetings were promptly documented, investigated, and resolved. Over several months, RC meeting minutes consistently recorded concerns regarding delayed call light response times, particularly on the third shift, staff turning off call lights before addressing residents' needs, and inconsistent water pass. Despite these recurring issues being documented as both old and new business in multiple RC meetings, the 'Actions taken' sections were frequently left blank or marked as 'ongoing,' with no clear evidence of resolution or follow-up. During an RC meeting, all nine participants confirmed that assistance was not provided in a timely manner on the third shift, with one resident reporting a wait of several hours for help after activating the call light. Residents expressed frustration that their repeated complaints were not being taken seriously by facility leadership, with some stating they had stopped voicing concerns to the Nursing Home Administrator (NHA) or Director of Nursing (DON) due to a lack of meaningful response. Several residents described receiving generic assurances without observable improvement, and the issues would temporarily improve before recurring. The NHA acknowledged awareness of the concerns and described a staffing schedule change, but the report does not indicate that these actions effectively addressed the residents' grievances.

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