Failure to Address and Resolve Resident Grievances Related to Care and Treatment
Penalty
Summary
The facility failed to resolve grievances related to care and treatment for four residents, as required by its own grievance policy. The policy states that all complaints or grievances will be resolved promptly and fairly, and that residents, their representatives, or other interested parties are encouraged to bring concerns to the attention of the Administrator, who serves as the Grievance Officer. However, a review of the facility's grievance records from January through April 2025 showed no documentation of grievances from the four residents or their family member regarding care and treatment concerns, despite multiple interviews indicating that such concerns had been raised. Specifically, one resident reported repeated requests for lab and test results without resolution, while another expressed ongoing issues with noise and smoke from a resident smoking area outside their window, affecting their ability to open the window and sleep. A third resident stated they had been without their BIPAP machine for several days despite asking multiple staff members for assistance. Additionally, a family member of another resident reported multiple unresolved care concerns, including the location of the smoking area, resident hydration, and the timing of morning care. The Nursing Home Administrator confirmed that the facility's grievance process typically only addressed missing or broken items and acknowledged the lack of evidence that these care and treatment concerns were addressed in a timely manner.