Failure to File and Investigate Grievance for Resident's DPOA
Summary
A deficiency was identified when the facility failed to file and investigate a grievance for one resident out of three reviewed for grievances. The issue arose when the resident's Durable Power of Attorney (DPOA) visited the facility and complained to the Director of Nursing (DON) about the resident being discharged and transferred to another facility without her approval or notification. The DPOA expressed significant dissatisfaction with the lack of communication regarding the discharge and expected the facility to address her concerns. Upon review, it was found that the DPOA held financial authority only, as indicated by the Durable Power of Attorney form. Despite this, the facility's policy clearly stated that any resident or anyone acting on their behalf could file a grievance, and staff were required to assist in filing and investigating such grievances. The DON acknowledged the DPOA's complaint and passed it to the Social Service Director for follow-up, but no documentation was found to show that the complaint was investigated or that the DPOA was informed of any outcome. The Social Services Assistant confirmed that no investigation or resolution was pursued, and the DPOA was not communicated with regarding the complaint. Interviews with facility leadership, including the DON, Social Services Assistant, and Nursing Home Administrator (NHA), revealed a misunderstanding or misapplication of the facility's grievance policy. The NHA believed that the financial-only DPOA was not acting on the resident's behalf in a medical capacity and therefore did not warrant follow-up. However, both the DON and Social Services Assistant later confirmed that the DPOA's complaint should have been treated as a valid grievance according to facility policy, but it was not filed, investigated, or resolved as required.
Plan Of Correction
1. On , a grievance was initiated by the Social Service assistant for resident #1 regarding the resident's fiduciary DPOA concern regarding resident #1 being discharged to another center without their knowledge. A final resolution was delivered to the fiduciary DPOA on . 2. By an audit of current residents was completed by the Social Service Manager to ensure any resident with power of attorney is clarified on the sheet to ensure proper notification of any discharge plans. On the Director of Nursing was re-educated by the NHA to ensure any concerns are brought to the interdisciplinary team as a grievance and a conclusion/resolution is brought to the person filing the grievance. By staff were re-educated on the Grievance process by the Staff development coordinator. 3. Random interviews of residents/family/visitors 3 times a week for 12 weeks to ensure all concerns are brought through the grievance process. Interviews to be conducted by social services. 4. Interviews will be brought to the Quality Assurance and Assessment/Quality Assurance Performance Improvement committee for a minimum of three months or until substantial compliance is achieved.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Grievance Procedure Information Not Posted or Discussed: The facility failed to make grievance/complaint filing information available to 10 of 10 residents reviewed. Residents stated they did not know they could file anonymously, did not know where to get or submit a grievance form, and were unaware of their right to a written decision. Observation showed prominent postings lacked grievance instructions, and the ADM stated he was the grievance officer and that the grievance process should have been discussed in Resident Council.
A resident grievance about a missing hearing aid was not fully investigated, documented, resolved, or communicated to the resident’s family member. The facility only documented an initial search of the room, bedding, and laundry, with no further follow-up in the resident’s chart. The SSD said the grievance had been assigned to someone else and no outcome was shared, while the family member reported receiving no updates. The DON confirmed there was no documented follow-up and that grievances were expected to be resolved within five days.
Failure to initiate a grievance after a resident reported that staff turned off the call light without providing assistance. The resident, who had pneumonia, CKD, and DM, said they needed help to use the restroom, but a staff member turned off the call light and did not return for 15 to 20 minutes. The concern was reported to an LPN, and the Administrator stated no grievance or investigation was initiated.
Failure to Process Resident Grievances: A resident’s RP and the Ombudsman raised concerns about repeated denial of access to the resident’s medical records, but the facility did not generate grievance reports and treated the issue as a records request matter rather than a grievance. The RP also alleged the resident was injured by staff during incontinent care, and the DON stated no grievance or self-report was made. The resident had severe cognitive impairment, was not interviewable, and had diagnoses including DM2, anxiety, adult failure to thrive, and vascular dementia.
Failure to Investigate and Document Resident Grievance: A resident with Parkinson's disease and other diagnoses reported that his roommate's loud TV and use of the heater were preventing sleep and making the room too hot to breathe. The resident said he had told the SW multiple times, but the concern was not resolved, was not included in the grievance file, and the LSW acknowledged she did not complete a grievance form or make follow-up.
The facility failed to fully document and log a resident grievance. A resident reported an incident involving a housekeeping employee making a comment in front of the resident’s visitor, but the staff section of the encounter form was left blank and the grievance was not entered on the encounter log. The CNO confirmed the incomplete documentation and missing log entry.
Grievance Procedure Information Not Made Available to Residents
Penalty
Summary
The facility failed to make information on how to file a grievance or complaint available to residents for 10 of 10 confidential residents reviewed for grievances. During interviews, all 10 residents stated they did not know they could file a grievance anonymously, did not recall the grievance procedure being discussed in Resident Council, and had not observed a posting of the grievance procedure in prominent locations. The residents also stated they did not know where to obtain a grievance form, who to give it to, what happened after a grievance was filed, or that they had the right to receive a written decision once their grievance was resolved. Observation of prominent postings on 06/16/2026 at 4:25 PM showed the facility did not include instructions regarding the grievance procedure with the postings. During interview on 06/17/2026 at 10:15 AM, the ADM stated he was the grievance officer, that grievance forms were available on a shelf by the downstairs elevator and could also be obtained from any staff member, and that grievances were assigned to the appropriate department for resolution and documented on the grievance form. The ADM stated completed grievance forms were kept in a notebook for 3 plus years, that grievances were monitored in daily IDT meetings, and that he was not aware the grievance procedure was not being discussed in Resident Council. The grievance policy reviewed, last updated in January 2024, stated grievance forms would be kept in the foyer on each floor, any staff member could assist with completing the form, and completed forms would be given to social services.
Failure to Investigate and Communicate a Grievance About a Missing Hearing Aid
Penalty
Summary
The facility failed to ensure a resident grievance regarding a missing hearing aid was fully investigated, documented, resolved, and communicated to the resident representative in accordance with facility policy for one resident. The resident’s Customer Concern/Grievance, filed by a family member, reported that the hearing aid was missing. The facility documented an initial search of the room, bedding, and laundry, but no further investigation, follow-up, or resolution was documented. The resident’s progress notes from the date of the grievance through several weeks later contained no documentation about the missing hearing aid or grievance follow-up. During interviews, the SSD acknowledged receiving the grievance but stated it had been assigned to another person and no outcome had been communicated, the family member reported receiving no updates or information after filing the concern, and the DON confirmed there was no documented follow-up and that grievances were expected to be resolved within five days with the complainant updated on progress and outcome.
Failure to Initiate Grievance for Resident Concern About Call Light Response
Penalty
Summary
The facility failed to initiate a grievance after Resident 138 raised a concern about staff customer service. Resident 138 was admitted with pneumonia, chronic kidney disease, and diabetes, and was able to make needs known. During observation and interview, Resident 138 was sitting in a wheelchair just inside the room door with an upset expression and stated they had turned on the call light because they needed help to use the restroom. Resident 138 stated a staff member entered the room, turned off the call light, and said they would return to assist, but the resident waited 15 to 20 minutes for the staff member to come back and was upset about having to wait. The concern was reported to an LPN, and during interview the Administrator stated that if a resident reported staff had turned off the call light without providing care, a grievance should be completed. The Administrator also stated that turning off the call light without providing care increased the likelihood of neglect if the staff member forgot to return. The Administrator stated no grievance or investigation was initiated in response to Resident 138's concern, and this did not meet expectations.
Failure to Process Resident Grievances
Penalty
Summary
The facility failed to ensure that a resident’s representative could voice grievances without discrimination or reprisal and failed to establish grievance reports for concerns raised by the resident’s representative and the Ombudsman. Resident #30 was an elderly female with diagnoses including type 2 diabetes, anxiety disorder, adult failure to thrive, and vascular dementia, and her quarterly MDS reflected a BIMS score of 04 indicating severe cognitive impairment. She was not interviewable during observation because she responded inappropriately to questions. The resident’s representative stated she had requested access to the resident’s medical records for two years and had been denied both times. She reported bringing her concerns to Medical Records, Social Worker, DON, and Administrator, but said there was no resolution and only delays. The Ombudsman also reported concerns about the representative’s denial of access to the medical records and stated the situation was ongoing and unusual. The Social Worker stated the representative wanted the records, was directed back to Medical Records, and was told to submit another request or ask for the denial reason, but the concern was not tracked as a grievance because it was viewed as a quick resolution. The DON stated the representative’s concerns were discussed during the care plan meeting, but she did not recall all details and believed there was no need to file a grievance. The Administrator stated the facility denied access to the records because of an invalid address and what she believed was an invalid POA in the chart, and later found an old POA in storage naming the representative to make all health care decisions. The report also states the representative contacted law enforcement alleging the resident was injured by facility staff after incontinent care, and the DON said no grievance or self-report was made about that incident.
Failure to Investigate and Document Resident Grievance
Penalty
Summary
The facility failed to ensure grievances were investigated and prompt corrective action was taken to resolve them for Resident #6. The resident was admitted and later readmitted with multiple diagnoses, including aftercare following surgery on the skin and subcutaneous tissue and Parkinson's disease with dyskinesia. On 5/26/26 at 10:27 AM, the resident stated he was unable to sleep because his roommate's TV was too loud and that the roommate was turning the heater on, making the room too hot and difficult to breathe. The resident said he had reported these concerns to the Social Worker three times, including that morning, but nothing had changed. Review of the facility's grievance file did not include the resident's concerns about his roommate. On 5/26/26 at 2:19 PM, the LSW stated the resident had expressed concerns about his roommate and that she spoke to the roommate, who denied turning on the heater. The LSW stated headphones were offered, but the roommate refused, and the resident said he would wear headphones only if the roommate did too. The LSW stated the resident raised the concern again that morning and it was not resolved. She also stated she failed to complete a grievance form for the resident and did not make a follow-up, acknowledging that she should have.
Incomplete grievance documentation and missing log entry
Penalty
Summary
The facility failed to provide complete documentation in response to a resident concern and failed to log concerns for one of three residents, Resident R53. The facility policy stated that grievances may be voiced in writing or orally, that the Grievance Official or designee is responsible for overseeing the grievance process and tracking grievances to conclusion, and that the Grievance Official or designee will investigate and provide follow-up within 72 hours. Resident R53’s Pink Encounter Form documented a report of an incident that occurred when Housekeeping Employee E8 made a comment to the resident in front of the resident’s visitor, but the section to be completed by facility staff was blank on review. The facility’s May 2026 Encounter Form Log also did not include Resident R53’s grievance. The Chief Nursing Officer confirmed that the facility failed to provide complete documentation in response to the resident concern and failed to log concerns for one of three residents.
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