Failure to Resolve and Document Resident Grievances
Penalty
Summary
The facility failed to act promptly on grievances reported during resident council meetings and did not provide adequate responses to grievances for six of nine residents, as evidenced by a review of resident council meeting minutes and grievance forms. Concerns and complaints, such as missing clothing, inappropriate food options, and removal of a phone that provided privacy, were repeatedly documented over several months without resolution or proper documentation indicating that the issues had been addressed. Grievance forms were found to be incomplete, lacking documentation of resolution and resident signatures to confirm satisfaction with outcomes. Residents expressed ongoing frustration during council meetings, reporting that missing clothing issues persisted for weeks or months, with some residents observing others wearing their clothes and staff failing to act when notified. Additional concerns included being served food that did not meet dietary needs or preferences, repeated offering of undesirable alternatives, and the removal of a phone that previously allowed for private conversations. Multiple residents reported receiving cold food, sour milk, and food they were allergic to, with all nine residents at the meeting sharing that their grievances remained unresolved. Interviews with facility staff revealed a lack of consistent follow-through in the grievance process. The Activity Director and other staff described the process for handling grievances but acknowledged that forms were not always completed fully or signed by residents to indicate satisfaction. The Housekeeping Director detailed ongoing issues with the laundry process, including improper labeling of clothing and incomplete personal item lists, which contributed to the unresolved complaints about missing clothing. Despite these issues being discussed in daily meetings, no changes had been made to address the underlying problems.