Failure to Inform and Implement Grievance Process
Summary
The facility failed to inform and educate residents about the grievance process and did not effectively implement procedures for documenting, tracking, and resolving grievances. During a confidential group meeting, all six residents present reported that they repeatedly discussed the same concerns in resident council meetings without resolution. These residents were unaware that they could have their private concerns documented on a form, that staff could assist them in completing the form, or that they could submit concerns anonymously. They also did not know that concern forms were available or how to access them, but indicated they would use the forms if they were accessible. Observations revealed that blank concern forms were stored in a binder on a shelf located 4-5 feet up on the wall in a sitting area near the main lobby, making them not easily accessible to residents. Interviews with staff, including an LPN and two Activity Associates, showed a lack of awareness about the location and use of concern forms. The LPN stated she did not know where to find the forms or assist residents with them, and one Activity Associate was unfamiliar with the forms altogether. The other Activity Associate, who conducted resident council meetings, reported that she emailed concerns to relevant departments but did not follow up to ensure concerns were addressed, only discussing responses from previous meetings if available. Further interviews with facility leadership, including the Nursing Home Administrator and DON, confirmed that concern forms were not placed in areas frequented by residents and were posted high on the wall, making them difficult to access. The DON also noted that staff, rather than residents, typically initiated the concern forms. As a result, the facility did not ensure that residents were properly informed about their right to file grievances, did not make the process accessible, and failed to document, track, and record the resolution of grievances as required.
Plan Of Correction
1. The facility moved concern/grievance forms to a tabletop location that is prominent and easily accessible in the lobby. A prominent notice was placed to guide residents to the location. 2. All residents who have concerns about their care have potential to be affected. 3. The facility created a log of concerns and grievances to monitor follow-up and ensure each concern is resolved. The log also enables the facility to track and trend concerns to identify opportunities for continuous quality improvement. The facility will report the number and nature of concerns, resolution status, and trends at monthly Quality Assurance Performance Improvement (QAPI) meetings, where the QAPI Committee will use the information to direct performance improvement projects as warranted. The facility will also provide written information to all residents on the right to air concerns or grievances, and the location of self-reporting forms. This information will be provided to the Resident Council at the July meeting. Going forward, this information will also be included in the admission packet. Education will be provided to all employees about the right to air concerns and grievances, and how residents can submit concerns or grievances using forms that are available in the lobby or with confidential help from an employee. Education will include how these are tracked for continuous quality improvement. 4. During routine daily leadership rounds, each leader will interview at least one resident for awareness how to report a concern or grievance for at least the next 12 weeks. During monthly QAPI meetings the committee will review the number, nature and status of concerns and will determine if opportunities are present for performance improvement. 5. The executive director is responsible for compliance.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Grievance Information Not Posted or Accessible: The facility failed to provide 7 confidential residents with accessible information on how to file grievances or concerns. During Resident Council, residents stated they did not know they could file grievances anonymously and had not seen the grievance procedure posted in prominent locations. Surveyors observed the lobby postings did not include the grievance policy, filing instructions, or where to obtain a form, while the ADM stated forms were available near the staff break room and could be submitted anonymously in the same box as blank forms.
A facility failed to ensure grievance forms available at one of the grievance information locations included wording that a grievance could be filed anonymously. Although the grievance policy stated complaints may be submitted orally or in writing and may be filed anonymously, the policy/procedure was not posted at the Willow Unit location, and the grievance forms there did not mention anonymous filing. The NHA confirmed the omission.
Failure to Resolve Representative’s Grievance About Morphine Use: A resident with Alzheimer’s disease, severe cognitive impairment, a pressure ulcer, and hospice services had a care plan meeting where her RP said morphine made her sedated and confused, asked that he be notified before any MS was given, and requested routine acetaminophen instead. The request was not entered as a grievance, was not documented in the resident’s record, and staff later gave MS without notifying the RP. Interviews showed the MDS Coordinator and DON did not follow up on the complaint, and the grievance log had no entry for the resident.
Delayed Follow-Up on Missing Dentures: A resident with Alzheimer’s disease and severe cognitive impairment was observed eating without teeth after missing dentures were not followed up on timely. The SSD was first notified by family that the dentures were missing, but did not pursue the issue with the dental consultant for more than a month. The resident’s SLP noted the resident took longer to chew food because the resident did not have teeth.
Failure to File and Investigate Resident Grievance: A resident reported that a CNA made a false statement after he helped his roommate following a fall, but the concern was not filed as a grievance or investigated. The grievance log only showed an unrelated grievance about inconsistent care, and the SS Director stated she did not complete a grievance because that was not how grievances worked; the ADON and DON stated the grievance should have been filed and investigated.
A resident’s family grievance about staff not waking the resident and getting him out of bed was not documented or investigated, despite the administrator speaking with the family member. In a separate issue, a cognitively intact resident reported that clothing packed during an evacuation was missing after return to the facility, and the missing items were not satisfactorily resolved; staff searched for the bag, but it was not found and the administrator acknowledged the facility was responsible for the clothing.
Grievance Information Not Posted or Accessible
Penalty
Summary
The facility failed to provide information to residents and their representatives about how to file grievances or concerns for 7 of 15 confidential residents. During Resident Council on 08/12/2026 at 11:00am, 7 confidential residents stated they did not know they could file a grievance anonymously and had not seen a posting of the grievance procedure in prominent locations. The residents attending the council stated there was no system for submitting a grievance anonymously, and all 7 residents had lived in the facility for more than 6 months. On 08/12/2026 at 1:45pm, surveyors observed the prominent postings in the lobby area and found no grievance policy, no instructions for filing a grievance, and no directions for where a grievance form was available. On 08/13/2026 at 11:30am, the ADM stated she was the grievance officer, that grievance forms were available down a hallway by the staff break room, and that residents could anonymously leave completed forms in the same box as the empty forms. The ADM also stated grievances were assigned to department heads, were intended to be resolved within 5 days, and were documented on the original grievance form, which was kept in a notebook for 3 years. The facility's grievance policy, revised January 2017, stated residents and representatives could file grievances orally, in writing, or anonymously, and that a copy of the grievance/complaint procedure was to be posted on the resident bulletin board.
Grievance Information Missing Anonymous Filing Option
Penalty
Summary
The facility failed to ensure that grievance forms could be filed anonymously in one of four locations where grievance information was available, specifically on the Willow Unit. The facility policy on grievances, last reviewed 3/1/26, stated that grievances and/or complaints may be submitted orally or in writing and may be filed anonymously. However, during an observation on 8/4/26 at 8:04 a.m., the grievance policy/procedure was not posted at the location on the [NAME] Unit, and the grievance forms available at the grievance box location did not include wording stating that a grievance form can be filed anonymously. During an interview on 8/6/26 at 3:30 p.m., the Nursing Home Administrator confirmed that the facility grievance policy and procedure failed to provide information on residents' right to file a grievance anonymously.
Failure to Resolve Representative’s Grievance About Morphine Use
Penalty
Summary
The facility failed to ensure prompt efforts were made to resolve a grievance voiced by a resident’s representative during a care plan meeting. The resident was a 92-year-old female with Alzheimer’s disease, anemia, a pressure ulcer of the right heel, severe cognitive impairment with a BIMS score of 3, and hospice services. Her care plan addressed chronic pain and included analgesia as ordered, with evaluation of pain interventions each shift and as needed. Her physician orders included acetaminophen 500 mg every 6 hours as needed and morphine sulfate 15 mg every 4 hours as needed for pain. During the care plan conference, the resident’s representative stated that narcotic medication caused the resident to become sedated and confused, requested that morphine sulfate not be given unless he was first notified, and asked to add routine acetaminophen to help with repositioning and reduce the need for morphine. The conference note reflected that hospice would be contacted for orders. However, the resident’s record did not contain documentation that the representative’s request to be notified before morphine administration was entered into the medical record, and the facility grievance log for that month had no entry for the resident. The resident later received morphine sulfate once, and the medical record did not show that the representative was notified before administration. Staff interviews showed the RN was unaware of any instruction to call the family before giving morphine, the MDS Coordinator stated the representative’s complaints during the care plan meeting should have been translated into a grievance and followed up on but were not, and the DON stated she did not follow up on the complaints voiced during the meeting. The facility grievance policy stated that residents have the right to voice grievances without discrimination or reprisal and that the facility must make prompt efforts to resolve grievances.
Delayed Follow-Up on Missing Dentures
Penalty
Summary
The facility failed to ensure that one resident’s missing dentures were followed up with the dental consultant in a timely manner. The resident had Alzheimer’s disease with late onset, lacked the capacity to understand and make decisions, and had severe cognitive impairment on the MDS dated 7/2/2026. The resident also required substantial to maximal assistance with ADLs, including bathing, dressing, rolling, and transferring. On 7/23/2026, the resident was observed eating in the dining room without teeth. The speech therapy evaluation dated 6/29/2026 indicated that because the resident did not have teeth, the resident took longer to chew food. The social services director stated she was first made aware by the resident’s family member on 6/16/2026 that the dentures were missing, but did not follow up on the dentures until 7/23/2026, more than one month later. The resident had a dental evaluation on 6/23/2026, but it did not indicate whether the resident was seen for dentures. The social services director stated the delay was not acceptable and that the denture referral was not followed up timely.
Failure to File and Investigate Resident Grievance
Penalty
Summary
The facility failed to ensure a resident’s concern about a CNA’s false statement was treated as a grievance and investigated for one of three reviewed residents. Resident #8 stated that after he assisted his roommate following a fall, a CNA later said he had not helped her, and he reported this concern to the Social Services Director. The resident said no one investigated his allegation, and after he spoke with Social Services, he was asked whether he wanted to transfer because he was unhappy with the facility. He stated that he did not want to transfer and wanted to remain at the facility. Review of the grievance log showed a grievance filed by Resident #8 on 4/8/2026 concerning inconsistent care, but there was no grievance related to the staff member’s false statement. The Social Services Director stated she was not aware of any grievance other than the April grievance and said she did not fill out a grievance because that is not how grievances work. The ADON stated she did not know why a grievance was not filed and that it should have been. The DON stated that a grievance should have been filed, investigated, and followed up in writing.
Failure to Document Grievance and Resolve Missing Clothing Complaint
Penalty
Summary
The facility failed to ensure that a resident’s grievance was documented and promptly investigated after the resident’s responsible party called to complain that staff were not waking the resident and getting him out of bed. The resident was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting his left non-dominant side, polyneuropathy, benign prostatic hyperplasia, insomnia, pain, and peripheral vascular disease. The responsible party stated she called the facility and spoke with a nurse about the concern, and later spoke with the administrator about the same issue. Interviews with the DON and SSD confirmed there was no documentation of the complaint. The administrator confirmed he spoke with the responsible party after her call, but he did not document the grievance and the facility did not investigate it. The facility’s grievance policy stated grievances were to be documented and thoroughly investigated, with prompt efforts to resolve them. The facility also failed to satisfactorily resolve a grievance involving a resident’s missing clothing after evacuation to a sister facility. The resident, who was cognitively intact with a BIMS score of 15 and had diagnoses including multiple sclerosis, spinal stenosis, and chronic pain, reported that a bag containing three days of clothing was missing after she returned to the facility. She stated the missing clothing included items she needed and preferred to wear, and that she remained without those clothes for about a month after returning. The grievance record showed staff checked the laundry room, spoke with housekeeping, and searched other closets, but the bag and clothing were not found. Interviews confirmed the clothing had been packed for evacuation, was not returned with the resident, and may have been left at the sister facility or lost in transfer. The administrator acknowledged it was the facility’s responsibility to ensure the clothing was packed and returned, and stated he should have replaced the resident’s clothing.
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