Failure to Timely Address Resident Grievance Regarding Mattress and Pain
Summary
The facility failed to timely initiate and address a grievance for a resident who had ongoing complaints about discomfort caused by her mattress and back pain. The resident, who had a diagnosis of cellulitis in the right lower limb and a wound to the right heel, repeatedly informed staff that her mattress was uncomfortable and exacerbated her back pain. She reported her concerns to multiple staff members, including certified nurse aides and a nurse, and requested a different mattress and a recliner, which she had used at home. Despite these repeated complaints, no grievance was formally documented, and her requests were not addressed in a timely manner. The resident spent extended periods in her wheelchair due to the discomfort and was told on several occasions that a recliner could be provided, but this was not followed through until later. Interviews with facility staff revealed that the Director of Nursing was not aware of the resident's complaints or requests, and the staff assigned to check on the resident daily did not document or escalate the grievance. Additionally, registered nurses on the unit indicated that grievance forms were not readily available, and their process for handling concerns was to notify the relevant department or unit manager rather than completing a formal grievance form. The facility's policies required that grievances be documented immediately and investigated, but this process was not followed for the resident's ongoing complaints.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility did not provide residents with information about the grievance process or how to file a grievance. Multiple residents, including those who were cognitively intact and involved in resident council, were unaware of their rights or the process, and staff also lacked knowledge. No information was posted in the facility, despite policies requiring residents be informed and assisted in filing grievances.
Residents reported and records confirmed significant delays in call light response times, with some waiting over an hour for assistance. Despite staff education on timely response, there was no evidence of follow-up or monitoring, and grievances about the issue remained unresolved, affecting multiple residents.
The facility did not address or follow up on 30 out of 75 resident grievances and multiple concerns raised during Resident Council meetings, including issues with medication administration, food quality, staffing, and care preferences. Documentation and follow-up actions were inconsistent, and interviews with the DON and Administrator confirmed that required grievance procedures were not followed.
A resident's family reported a missing lamp, which was removed from the room by staff and later found in the maintenance office. The facility did not document or address the grievance in accordance with its policy, and there was no evidence of a timely investigation or resolution.
A resident with multiple chronic conditions reported missing clothing items, providing detailed lists to Social Services and communicating concerns to the Administrator. Despite these reports, the facility did not thoroughly investigate, document, or follow up on the grievances, and the missing items were not entered into the grievance log. The resident and family ultimately replaced the lost items themselves, with no resolution or reimbursement from the facility.
A resident with severe dementia and multiple psychiatric diagnoses alleged physical abuse by another resident. The resident's guardian reported the allegation and requested to be informed of the investigation's outcome. Despite multiple follow-up requests, the facility did not notify the guardian of the investigation results, nor was there documentation of the communication or the incident in the clinical record.
Failure to Inform Residents of Grievance Process
Penalty
Summary
The facility failed to provide residents with information regarding the grievance process and how to file a grievance, as required by policy. Record review and interviews revealed that three residents, including one who was cognitively intact and served as the presiding president of the Resident Council, were unaware of their right to file a grievance or the process for doing so. These residents reported that the grievance process had never been explained to them individually or during resident council meetings. One resident with moderate cognitive impairment also indicated he was unaware of the process and could not recall it being discussed at meetings he attended. Further investigation showed that there was no posted information about the grievance process in the facility, and the Assistant Director of Nursing confirmed a lack of knowledge about how the process worked. Although the Administrator was able to provide a written policy and the names of the grievance committee members, there was no evidence that this information was communicated to residents. The facility's own policies stated that residents have the right to file grievances orally or in writing and that the facility should assist residents in exercising this right, but these procedures were not being followed or made known to residents.
Failure to Resolve Resident Grievances Regarding Call Light Response
Penalty
Summary
The facility failed to ensure that resident grievances regarding the timely answering of call lights were resolved appropriately and within a reasonable timeframe. Multiple records, including in-service documentation, grievance logs, and resident council minutes, indicated ongoing concerns about delayed call light responses. Specific incidents were documented where residents waited extended periods, ranging from over 26 minutes to more than two hours, for their call lights to be answered. Residents consistently reported long wait times during interviews, and the issue was also raised during resident council meetings. Despite staff being in-serviced on the importance of timely call light response, there was no evidence of follow-up audits or monitoring to ensure compliance. The facility's grievance policy required immediate action to prevent further violations of resident rights, but the lack of timely resolution and monitoring led to repeated and unresolved complaints from residents. This deficiency affected nine residents and was substantiated through multiple sources, including direct resident interviews and review of facility records.
Failure to Address and Follow Up on Resident Grievances and Council Concerns
Penalty
Summary
The facility failed to address and follow up on resident grievances and concerns in a timely manner, as evidenced by a review of facility documents, staff interviews, and policy review. Out of 75 grievances filed between April 2025 and September 2025, 30 had not been followed up on. Additionally, multiple concerns raised during Resident Council meetings from June through October 2025—including issues with untimely medication administration, undercooked food, staffing, staff approach, and showers—were not addressed or followed up on. The facility census at the time was 70 residents, indicating that the failure had the potential to affect all residents. Further review revealed inconsistencies in documentation and follow-up actions. For example, meeting minutes from August 2025 indicated that an LPN had been counseled for untimely medication administration, but the personnel file contained no documentation to support this. Interviews with the DON and Administrator confirmed that the grievances and concerns had not been addressed as required by facility policy, which designates the Administrator as the Grievance Official responsible for oversight and written decisions. The facility's policy also requires action and communication regarding Resident Council concerns, which was not followed.
Failure to Timely Address and Document Resident Grievance Regarding Personal Property
Penalty
Summary
The facility failed to document and address a grievance made by a resident's representative in a timely manner. A resident, who was cognitively intact and had multiple complex medical diagnoses, was discharged to the hospital for ongoing medical issues. During his stay, the resident's family reported a missing lamp, which was later found in the facility's maintenance office. The lamp had been removed from the resident's room by the Plant Operations Director after it was discovered that it was plugged into an extension cord. The Plant Operations Director informed the resident about the removal, but there was no documented response from the resident. The family left a note on the resident's door requesting the return of the lamp, and the Administrator acknowledged being aware of this request. However, the Administrator did not return the lamp to the family and was unable to provide documentation of any grievance investigation, resident concern form, or resolution to the grievance. The facility's policy required concerns to be entered electronically and resolved within 24-48 hours, but there was no evidence that this process was followed in this case.
Failure to Investigate and Document Resident Grievances Regarding Missing Personal Items
Penalty
Summary
The facility failed to thoroughly investigate and document grievances related to missing personal items for a resident. The resident, who was cognitively intact and had multiple medical diagnoses including morbid obesity, type II diabetes, anxiety disorder, and stage III chronic kidney disease, reported that several items of clothing had gone missing while residing in the locked unit. Despite providing detailed lists of missing items to Social Services, and the family also communicating concerns to the Administrator, the facility did not conduct a comprehensive investigation or follow up with the resident or her family to resolve the issue. The resident's concerns were not entered into the facility's grievance log, and there was no documented inventory of her personal items in the medical record. Interviews with staff revealed that Social Services received multiple lists of missing clothing from the resident over several days and attempted to locate some items in the resident's room and laundry, marking off what was found. However, Social Services did not follow up on the remaining missing items, assuming the issue was resolved when it was not mentioned again. The Administrator also acknowledged being informed of the missing items by the resident's family but did not pursue further investigation or communication after initially requesting a list of missing items from the family, which was not received. The Director of Nursing confirmed that the resident's concerns were not documented in the grievance log as required by facility policy. Facility policy required immediate action and a timely investigation upon receipt of any grievance, whether oral or written, to prevent further violations. Despite this, the facility did not document or investigate the resident's repeated reports of missing clothing, nor did it communicate outcomes or resolutions to the resident or her family. The lack of follow-up and documentation resulted in the resident and her family having to replace the missing items themselves, with the value of the lost clothing estimated at around $600.
Failure to Notify Guardian of Abuse Investigation Results
Penalty
Summary
The facility failed to provide timely notification to a resident's guardian regarding the results of an investigation into an allegation of physical abuse. The resident, who had diagnoses including psychosis, malnutrition, severe dementia with agitation, cognitive communication deficit, drug-induced dyskinesia, mood disorder, bipolar disorder, and anxiety, resided on a secured nursing unit due to safety concerns and a history of elopement. The resident's care plan included interventions for her cognitive and behavioral needs. On the date in question, the resident alleged that another resident had assaulted her in her room. The guardian, present at the time, reported the allegation to facility staff and requested to be informed of the investigation's outcome. Despite the guardian's repeated requests for updates via email and in person, there was no documentation that the facility notified the guardian of the investigation results. The facility's records did not reflect any communication with the guardian regarding the outcome, nor did they document the alleged altercation or the abuse allegation in the resident's clinical record. The investigation concluded that no assault had occurred, but this information was not relayed to the guardian until it was brought to the attention of the surveyors during the interview process.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
