Failure to Maintain and Track Resident Grievances per Facility Policy
Penalty
Summary
The facility failed to ensure that all grievances filed during 2025 were available for review and appropriately followed up on, as required by their grievance policy. According to the facility's policy, once a grievance is filed, the Social Services Director (SSD) is responsible for reviewing and investigating the allegations, submitting a written report of findings to the administrator within five working days, and ensuring that a copy of the written summary is filed in the business office and maintained for three years. During the survey, it was found that the grievance binder, which should have contained records for each month, was empty. The SSD, who had only recently started working at the facility, and Social Services Staff 1 confirmed that there had been grievances filed during the year but were unable to locate most of them, with only one grievance eventually found. Interviews with the Administrator and Business Office Manager revealed that neither kept copies of the grievances, and the Business Office Manager was unaware that the policy required her to file copies of the written summaries. This lack of documentation prevented the state agency from verifying whether grievances were followed up on according to policy. The absence of grievance records indicated that the facility did not maintain the required documentation or ensure that grievances were handled and tracked as outlined in their procedures.